|
FAMILY TX W PT 50 MIN CHILD
|
Facility
|
OP
|
$1,500.00
|
|
|
Service Code
|
HCPCS 90847
|
| Hospital Charge Code |
4527517
|
|
Hospital Revenue Code
|
916
|
| Min. Negotiated Rate |
$36.15 |
| Max. Negotiated Rate |
$761.18 |
| Rate for Payer: Aetna Commercial |
$573.57
|
| Rate for Payer: Aetna Medicare Advantage |
$683.22
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$761.18
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$761.18
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage |
$210.87
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$164.38
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$761.18
|
| Rate for Payer: Cigna Commercial |
$422.69
|
| Rate for Payer: Cigna Medicare Advantage |
$210.87
|
| Rate for Payer: Clover Medicare Advantage |
$200.33
|
| Rate for Payer: EmblemHealth Commercial |
$632.61
|
| Rate for Payer: Humana Medicare Advantage |
$217.20
|
| Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage |
$210.87
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$450.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$225.00
|
| Rate for Payer: UnitedHealthcare Community & State |
$36.15
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$210.87
|
| Rate for Payer: Wellcare Medicare Advantage |
$210.87
|
| Rate for Payer: Wellcare New Jersey Medicaid/Family Care |
$113.84
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$39.75
|
|
|
FAMILY TX W PT 50 MIN CHILD
|
Facility
|
IP
|
$1,500.00
|
|
|
Service Code
|
HCPCS 90847
|
| Hospital Charge Code |
4515517
|
|
Hospital Revenue Code
|
916
|
| Min. Negotiated Rate |
$225.00 |
| Max. Negotiated Rate |
$225.00 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$225.00
|
|
|
FAMILY TX W PT 50 MIN CHILD
|
Facility
|
OP
|
$1,500.00
|
|
|
Service Code
|
HCPCS 90847
|
| Hospital Charge Code |
4546517
|
|
Hospital Revenue Code
|
916
|
| Min. Negotiated Rate |
$36.15 |
| Max. Negotiated Rate |
$761.18 |
| Rate for Payer: Aetna Commercial |
$573.57
|
| Rate for Payer: Aetna Medicare Advantage |
$683.22
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$761.18
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$761.18
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage |
$210.87
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$164.38
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$761.18
|
| Rate for Payer: Cigna Commercial |
$422.69
|
| Rate for Payer: Cigna Medicare Advantage |
$210.87
|
| Rate for Payer: Clover Medicare Advantage |
$200.33
|
| Rate for Payer: EmblemHealth Commercial |
$632.61
|
| Rate for Payer: Humana Medicare Advantage |
$217.20
|
| Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage |
$210.87
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$450.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$225.00
|
| Rate for Payer: UnitedHealthcare Community & State |
$36.15
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$210.87
|
| Rate for Payer: Wellcare Medicare Advantage |
$210.87
|
| Rate for Payer: Wellcare New Jersey Medicaid/Family Care |
$113.84
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$39.75
|
|
|
FAMILY TX W PT 50 MIN CHILD
|
Facility
|
OP
|
$1,500.00
|
|
|
Service Code
|
HCPCS 90847
|
| Hospital Charge Code |
4515517
|
|
Hospital Revenue Code
|
916
|
| Min. Negotiated Rate |
$36.15 |
| Max. Negotiated Rate |
$761.18 |
| Rate for Payer: Aetna Commercial |
$573.57
|
| Rate for Payer: Aetna Medicare Advantage |
$683.22
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$761.18
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$761.18
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage |
$210.87
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$164.38
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$761.18
|
| Rate for Payer: Cigna Commercial |
$422.69
|
| Rate for Payer: Cigna Medicare Advantage |
$210.87
|
| Rate for Payer: Clover Medicare Advantage |
$200.33
|
| Rate for Payer: EmblemHealth Commercial |
$632.61
|
| Rate for Payer: Humana Medicare Advantage |
$217.20
|
| Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage |
$210.87
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$450.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$225.00
|
| Rate for Payer: UnitedHealthcare Community & State |
$36.15
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$210.87
|
| Rate for Payer: Wellcare Medicare Advantage |
$210.87
|
| Rate for Payer: Wellcare New Jersey Medicaid/Family Care |
$113.84
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$39.75
|
|
|
FAMILY TX W PT 50 MIN CHILD
|
Facility
|
OP
|
$1,500.00
|
|
|
Service Code
|
HCPCS 90847
|
| Hospital Charge Code |
4824517
|
|
Hospital Revenue Code
|
916
|
| Min. Negotiated Rate |
$36.15 |
| Max. Negotiated Rate |
$761.18 |
| Rate for Payer: Aetna Commercial |
$573.57
|
| Rate for Payer: Aetna Medicare Advantage |
$683.22
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$761.18
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$761.18
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage |
$210.87
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$164.38
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$761.18
|
| Rate for Payer: Cigna Commercial |
$422.69
|
| Rate for Payer: Cigna Medicare Advantage |
$210.87
|
| Rate for Payer: Clover Medicare Advantage |
$200.33
|
| Rate for Payer: EmblemHealth Commercial |
$632.61
|
| Rate for Payer: Humana Medicare Advantage |
$217.20
|
| Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage |
$210.87
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$450.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$225.00
|
| Rate for Payer: UnitedHealthcare Community & State |
$36.15
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$210.87
|
| Rate for Payer: Wellcare Medicare Advantage |
$210.87
|
| Rate for Payer: Wellcare New Jersey Medicaid/Family Care |
$113.84
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$39.75
|
|
|
FAMILY TX W PT 50 MIN CHILD
|
Facility
|
OP
|
$1,500.00
|
|
|
Service Code
|
HCPCS 90847
|
| Hospital Charge Code |
4535517
|
|
Hospital Revenue Code
|
916
|
| Min. Negotiated Rate |
$36.15 |
| Max. Negotiated Rate |
$761.18 |
| Rate for Payer: Aetna Commercial |
$573.57
|
| Rate for Payer: Aetna Medicare Advantage |
$683.22
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$761.18
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$761.18
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage |
$210.87
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$164.38
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$761.18
|
| Rate for Payer: Cigna Commercial |
$422.69
|
| Rate for Payer: Cigna Medicare Advantage |
$210.87
|
| Rate for Payer: Clover Medicare Advantage |
$200.33
|
| Rate for Payer: EmblemHealth Commercial |
$632.61
|
| Rate for Payer: Humana Medicare Advantage |
$217.20
|
| Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage |
$210.87
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$450.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$225.00
|
| Rate for Payer: UnitedHealthcare Community & State |
$36.15
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$210.87
|
| Rate for Payer: Wellcare Medicare Advantage |
$210.87
|
| Rate for Payer: Wellcare New Jersey Medicaid/Family Care |
$113.84
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$39.75
|
|
|
FAMILY TX W PT 50 MIN CHILD
|
Facility
|
IP
|
$1,500.00
|
|
|
Service Code
|
HCPCS 90847
|
| Hospital Charge Code |
4535517
|
|
Hospital Revenue Code
|
916
|
| Min. Negotiated Rate |
$225.00 |
| Max. Negotiated Rate |
$225.00 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$225.00
|
|
|
FAMILY TX W PT 50 MIN CHILD
|
Facility
|
OP
|
$1,500.00
|
|
|
Service Code
|
HCPCS 90847
|
| Hospital Charge Code |
4504517
|
|
Hospital Revenue Code
|
916
|
| Min. Negotiated Rate |
$36.15 |
| Max. Negotiated Rate |
$761.18 |
| Rate for Payer: Aetna Commercial |
$573.57
|
| Rate for Payer: Aetna Medicare Advantage |
$683.22
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$761.18
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$761.18
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage |
$210.87
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$164.38
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$761.18
|
| Rate for Payer: Cigna Commercial |
$422.69
|
| Rate for Payer: Cigna Medicare Advantage |
$210.87
|
| Rate for Payer: Clover Medicare Advantage |
$200.33
|
| Rate for Payer: EmblemHealth Commercial |
$632.61
|
| Rate for Payer: Humana Medicare Advantage |
$217.20
|
| Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage |
$210.87
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$450.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$225.00
|
| Rate for Payer: UnitedHealthcare Community & State |
$36.15
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$210.87
|
| Rate for Payer: Wellcare Medicare Advantage |
$210.87
|
| Rate for Payer: Wellcare New Jersey Medicaid/Family Care |
$113.84
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$39.75
|
|
|
FAMILY TX W PT 50 MIN CHILD
|
Facility
|
OP
|
$1,500.00
|
|
|
Service Code
|
HCPCS 90847
|
| Hospital Charge Code |
4511517
|
|
Hospital Revenue Code
|
916
|
| Min. Negotiated Rate |
$36.15 |
| Max. Negotiated Rate |
$761.18 |
| Rate for Payer: Aetna Commercial |
$573.57
|
| Rate for Payer: Aetna Medicare Advantage |
$683.22
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$761.18
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$761.18
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage |
$210.87
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$164.38
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$761.18
|
| Rate for Payer: Cigna Commercial |
$422.69
|
| Rate for Payer: Cigna Medicare Advantage |
$210.87
|
| Rate for Payer: Clover Medicare Advantage |
$200.33
|
| Rate for Payer: EmblemHealth Commercial |
$632.61
|
| Rate for Payer: Humana Medicare Advantage |
$217.20
|
| Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage |
$210.87
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$450.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$225.00
|
| Rate for Payer: UnitedHealthcare Community & State |
$36.15
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$210.87
|
| Rate for Payer: Wellcare Medicare Advantage |
$210.87
|
| Rate for Payer: Wellcare New Jersey Medicaid/Family Care |
$113.84
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$39.75
|
|
|
FAMILY TX W PT 50 MIN CHILD
|
Facility
|
IP
|
$1,500.00
|
|
|
Service Code
|
HCPCS 90847
|
| Hospital Charge Code |
4546517
|
|
Hospital Revenue Code
|
916
|
| Min. Negotiated Rate |
$225.00 |
| Max. Negotiated Rate |
$225.00 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$225.00
|
|
|
FAMILY TX W PT 50 MIN CHILD
|
Facility
|
IP
|
$1,500.00
|
|
|
Service Code
|
HCPCS 90847
|
| Hospital Charge Code |
4511517
|
|
Hospital Revenue Code
|
916
|
| Min. Negotiated Rate |
$225.00 |
| Max. Negotiated Rate |
$225.00 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$225.00
|
|
|
FAMILY TX W PT 50 MIN CHILD
|
Facility
|
IP
|
$1,500.00
|
|
|
Service Code
|
HCPCS 90847
|
| Hospital Charge Code |
4510517
|
|
Hospital Revenue Code
|
916
|
| Min. Negotiated Rate |
$225.00 |
| Max. Negotiated Rate |
$225.00 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$225.00
|
|
|
FAMILY TX W PT 50 MIN CHILD
|
Facility
|
OP
|
$1,500.00
|
|
|
Service Code
|
HCPCS 90847
|
| Hospital Charge Code |
4822517
|
|
Hospital Revenue Code
|
916
|
| Min. Negotiated Rate |
$36.15 |
| Max. Negotiated Rate |
$761.18 |
| Rate for Payer: Aetna Commercial |
$573.57
|
| Rate for Payer: Aetna Medicare Advantage |
$683.22
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$761.18
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$761.18
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage |
$210.87
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$164.38
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$761.18
|
| Rate for Payer: Cigna Commercial |
$422.69
|
| Rate for Payer: Cigna Medicare Advantage |
$210.87
|
| Rate for Payer: Clover Medicare Advantage |
$200.33
|
| Rate for Payer: EmblemHealth Commercial |
$632.61
|
| Rate for Payer: Humana Medicare Advantage |
$217.20
|
| Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage |
$210.87
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$450.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$225.00
|
| Rate for Payer: UnitedHealthcare Community & State |
$36.15
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$210.87
|
| Rate for Payer: Wellcare Medicare Advantage |
$210.87
|
| Rate for Payer: Wellcare New Jersey Medicaid/Family Care |
$113.84
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$39.75
|
|
|
FAMILY TX W PT 50 MIN CHILD
|
Facility
|
OP
|
$1,500.00
|
|
|
Service Code
|
HCPCS 90847
|
| Hospital Charge Code |
4510517
|
|
Hospital Revenue Code
|
916
|
| Min. Negotiated Rate |
$36.15 |
| Max. Negotiated Rate |
$761.18 |
| Rate for Payer: Aetna Commercial |
$573.57
|
| Rate for Payer: Aetna Medicare Advantage |
$683.22
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$761.18
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$761.18
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage |
$210.87
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$164.38
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$761.18
|
| Rate for Payer: Cigna Commercial |
$422.69
|
| Rate for Payer: Cigna Medicare Advantage |
$210.87
|
| Rate for Payer: Clover Medicare Advantage |
$200.33
|
| Rate for Payer: EmblemHealth Commercial |
$632.61
|
| Rate for Payer: Humana Medicare Advantage |
$217.20
|
| Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage |
$210.87
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$450.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$225.00
|
| Rate for Payer: UnitedHealthcare Community & State |
$36.15
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$210.87
|
| Rate for Payer: Wellcare Medicare Advantage |
$210.87
|
| Rate for Payer: Wellcare New Jersey Medicaid/Family Care |
$113.84
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$39.75
|
|
|
FAMILY TX W PT 50 MIN CHILD
|
Facility
|
IP
|
$1,500.00
|
|
|
Service Code
|
HCPCS 90847
|
| Hospital Charge Code |
4822517
|
|
Hospital Revenue Code
|
916
|
| Min. Negotiated Rate |
$225.00 |
| Max. Negotiated Rate |
$225.00 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$225.00
|
|
|
FAMILY TX W PT 50 MIN CHILD
|
Facility
|
IP
|
$1,500.00
|
|
|
Service Code
|
HCPCS 90847
|
| Hospital Charge Code |
4509517
|
|
Hospital Revenue Code
|
916
|
| Min. Negotiated Rate |
$225.00 |
| Max. Negotiated Rate |
$225.00 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$225.00
|
|
|
FAMILY TX W PT 50 MIN CHILD
|
Facility
|
OP
|
$1,500.00
|
|
|
Service Code
|
HCPCS 90847
|
| Hospital Charge Code |
4517517
|
|
Hospital Revenue Code
|
916
|
| Min. Negotiated Rate |
$36.15 |
| Max. Negotiated Rate |
$761.18 |
| Rate for Payer: Aetna Commercial |
$573.57
|
| Rate for Payer: Aetna Medicare Advantage |
$683.22
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$761.18
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$761.18
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage |
$210.87
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$164.38
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$761.18
|
| Rate for Payer: Cigna Commercial |
$422.69
|
| Rate for Payer: Cigna Medicare Advantage |
$210.87
|
| Rate for Payer: Clover Medicare Advantage |
$200.33
|
| Rate for Payer: EmblemHealth Commercial |
$632.61
|
| Rate for Payer: Humana Medicare Advantage |
$217.20
|
| Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage |
$210.87
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$450.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$225.00
|
| Rate for Payer: UnitedHealthcare Community & State |
$36.15
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$210.87
|
| Rate for Payer: Wellcare Medicare Advantage |
$210.87
|
| Rate for Payer: Wellcare New Jersey Medicaid/Family Care |
$113.84
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$39.75
|
|
|
FAMILY TX W PT 50 MIN CHILD
|
Facility
|
IP
|
$1,500.00
|
|
|
Service Code
|
HCPCS 90847
|
| Hospital Charge Code |
4517517
|
|
Hospital Revenue Code
|
916
|
| Min. Negotiated Rate |
$225.00 |
| Max. Negotiated Rate |
$225.00 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$225.00
|
|
|
FAMOTIDINE 20 MG/ 2ML INJ
|
Facility
|
OP
|
$5.16
|
|
|
Service Code
|
NDC 641602201
|
| Hospital Charge Code |
60629059
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$2.58 |
| Rate for Payer: Aetna Commercial |
$1.96
|
| Rate for Payer: Aetna Medicare Advantage |
$1.55
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$1.32
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$1.32
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$1.32
|
| Rate for Payer: Cigna Commercial |
$2.58
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$1.55
|
| Rate for Payer: Oxford Commercial |
$1.03
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$0.77
|
| Rate for Payer: UnitedHealthcare Commercial |
$1.03
|
| Rate for Payer: UnitedHealthcare Community & State |
$0.12
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$0.14
|
|
|
FAMOTIDINE 20 MG/ 2ML INJ
|
Facility
|
IP
|
$5.16
|
|
|
Service Code
|
NDC 641602201
|
| Hospital Charge Code |
60629059
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.77 |
| Max. Negotiated Rate |
$0.77 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$0.77
|
|
|
FAMOTIDINE 20 MG TAB
|
Facility
|
OP
|
$11.59
|
|
|
Service Code
|
NDC 187442010
|
| Hospital Charge Code |
60629349
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$5.79 |
| Rate for Payer: Aetna Commercial |
$4.40
|
| Rate for Payer: Aetna Medicare Advantage |
$3.48
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$2.96
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$2.96
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$2.96
|
| Rate for Payer: Cigna Commercial |
$5.79
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$3.48
|
| Rate for Payer: Oxford Commercial |
$2.32
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1.74
|
| Rate for Payer: UnitedHealthcare Commercial |
$2.32
|
| Rate for Payer: UnitedHealthcare Community & State |
$0.28
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$0.31
|
|
|
FAMOTIDINE 20 MG TAB
|
Facility
|
IP
|
$11.59
|
|
|
Service Code
|
NDC 187442010
|
| Hospital Charge Code |
60629349
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.74 |
| Max. Negotiated Rate |
$1.74 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$1.74
|
|
|
FAMOTIDINE 40MG/5ML
|
Facility
|
IP
|
$509.75
|
|
| Hospital Charge Code |
6063943107
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$76.46 |
| Max. Negotiated Rate |
$76.46 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$76.46
|
|
|
FAMOTIDINE 40MG/5ML
|
Facility
|
OP
|
$509.75
|
|
| Hospital Charge Code |
6063943107
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.28 |
| Max. Negotiated Rate |
$254.88 |
| Rate for Payer: Aetna Commercial |
$193.71
|
| Rate for Payer: Aetna Medicare Advantage |
$152.93
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$129.99
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$129.99
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$129.99
|
| Rate for Payer: Cigna Commercial |
$254.88
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$152.93
|
| Rate for Payer: Oxford Commercial |
$101.95
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$76.46
|
| Rate for Payer: UnitedHealthcare Commercial |
$101.95
|
| Rate for Payer: UnitedHealthcare Community & State |
$12.28
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$13.51
|
|
|
FAMOTIDINE 40 MG/5 ML ORAL SUS
|
Facility
|
IP
|
$118.46
|
|
|
Service Code
|
NDC 68382044405
|
| Hospital Charge Code |
6063943199
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.77 |
| Max. Negotiated Rate |
$17.77 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$17.77
|
|
