|
APEX./RECAL.-INTERIM MEDICATION R
|
Facility
|
OP
|
$200.00
|
|
|
Service Code
|
HCPCS D3352
|
| Hospital Charge Code |
42300755
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$100.00 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$110.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,018.19
|
| Rate for Payer: Aetna Government |
$1,018.19
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$712.73
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$712.73
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$712.73
|
| Rate for Payer: Brighton Health Commercial |
$150.00
|
| Rate for Payer: Cash Price |
$1,018.19
|
| Rate for Payer: Cash Price |
$1,018.19
|
| Rate for Payer: Cash Price |
$1,018.19
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,018.19
|
| 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 |
$1,018.19
|
| Rate for Payer: EmblemHealth Commercial |
$1,018.19
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$865.46
|
| Rate for Payer: Fidelis Essential Plan QHP |
$906.19
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,018.19
|
| Rate for Payer: Fidelis Qualified Health Plan |
$906.19
|
| Rate for Payer: Group Health Inc Commercial |
$1,018.19
|
| Rate for Payer: Group Health Inc Medicare |
$1,018.19
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$100.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,018.19
|
| Rate for Payer: Healthfirst Medicare Advantage |
$865.46
|
| Rate for Payer: Healthfirst QHP |
$1,018.19
|
| Rate for Payer: Humana Medicare |
$1,038.55
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,018.19
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,018.19
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,018.19
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$814.55
|
| Rate for Payer: Wellcare Medicare |
$967.28
|
|
|
APHASIA EVAL, PER HR
|
Facility
|
OP
|
$298.45
|
|
|
Service Code
|
HCPCS 96105 GN
|
| Hospital Charge Code |
41904867
|
|
Hospital Revenue Code
|
444
|
| Min. Negotiated Rate |
$55.00 |
| Max. Negotiated Rate |
$222.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$164.15
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$92.08
|
| Rate for Payer: Aetna Government |
$92.08
|
| Rate for Payer: Brighton Health Commercial |
$182.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$147.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$124.95
|
| Rate for Payer: Group Health Inc Commercial |
$149.22
|
| Rate for Payer: Group Health Inc Medicare |
$120.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$149.22
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$149.22
|
| Rate for Payer: United Healthcare Commercial |
$222.00
|
| Rate for Payer: Wellcare Medicare |
$55.00
|
|
|
APHERESIS ADSORP/REINFUSE
|
Facility
|
OP
|
$11,564.85
|
|
|
Service Code
|
HCPCS 36516
|
| Hospital Charge Code |
30103089
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,505.00 |
| Max. Negotiated Rate |
$8,673.64 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,880.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$5,351.70
|
| Rate for Payer: Aetna Government |
$5,351.70
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$3,746.19
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$3,746.19
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$3,746.19
|
| Rate for Payer: Brighton Health Commercial |
$8,673.64
|
| Rate for Payer: Cash Price |
$5,351.70
|
| Rate for Payer: Cash Price |
$5,351.70
|
| Rate for Payer: Cash Price |
$5,351.70
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$5,351.70
|
| 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 |
$5,351.70
|
| Rate for Payer: EmblemHealth Commercial |
$1,505.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$4,548.94
|
| Rate for Payer: Fidelis Essential Plan QHP |
$4,763.01
|
| Rate for Payer: Fidelis Medicare Advantage |
$5,351.70
|
| Rate for Payer: Fidelis Qualified Health Plan |
$4,763.01
|
| Rate for Payer: Group Health Inc Commercial |
$5,351.70
|
| Rate for Payer: Group Health Inc Medicare |
$5,351.70
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$5,782.42
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$5,351.70
|
| Rate for Payer: Healthfirst Medicare Advantage |
$4,548.94
|
| Rate for Payer: Healthfirst QHP |
$5,351.70
|
| Rate for Payer: Humana Medicare |
$5,458.73
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$5,351.70
|
| Rate for Payer: United Healthcare Commercial |
$2,683.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5,351.70
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$5,351.70
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$4,281.36
|
| Rate for Payer: Wellcare Medicare |
$5,084.12
|
|
|
APHERESIS ADSORP/REINFUSE
|
Facility
|
IP
|
$11,564.85
|
|
|
Service Code
|
HCPCS 36516
|
| Hospital Charge Code |
30103089
|
|
Hospital Revenue Code
|
360
|
| Rate for Payer: Cash Price |
$5,351.70
|
|
|
APICALLY POSITIONED FLAP
|
Facility
|
OP
|
$312.50
|
|
|
Service Code
|
HCPCS D4245
|
| Hospital Charge Code |
42303306
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$156.25 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$171.88
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,763.60
|
| Rate for Payer: Aetna Government |
$1,763.60
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$1,234.52
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$1,234.52
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$1,234.52
|
| Rate for Payer: Brighton Health Commercial |
$234.38
|
| Rate for Payer: Cash Price |
$1,763.60
|
| Rate for Payer: Cash Price |
$1,763.60
|
| Rate for Payer: Cash Price |
$1,763.60
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,763.60
|
| 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 |
$1,763.60
|
| Rate for Payer: EmblemHealth Commercial |
$1,763.60
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$1,499.06
|
| Rate for Payer: Fidelis Essential Plan QHP |
$1,569.60
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,763.60
|
| Rate for Payer: Fidelis Qualified Health Plan |
$1,569.60
|
| Rate for Payer: Group Health Inc Commercial |
$1,763.60
|
| Rate for Payer: Group Health Inc Medicare |
$1,763.60
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$156.25
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,763.60
|
| Rate for Payer: Healthfirst Medicare Advantage |
$1,499.06
|
| Rate for Payer: Healthfirst QHP |
$1,763.60
|
| Rate for Payer: Humana Medicare |
$1,798.87
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,763.60
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,763.60
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,763.60
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$1,410.88
|
| Rate for Payer: Wellcare Medicare |
$1,675.42
|
|
|
APICALLY POSITIONED FLAP
|
Facility
|
IP
|
$312.50
|
|
|
Service Code
|
HCPCS D4245
|
| Hospital Charge Code |
42303306
|
|
Hospital Revenue Code
|
361
|
| Rate for Payer: Cash Price |
$1,763.60
|
|
|
APICOECTOMY/PERIRADICULAR SURG-BI
|
Facility
|
IP
|
$400.00
|
|
|
Service Code
|
HCPCS D3421
|
| Hospital Charge Code |
42300775
|
|
Hospital Revenue Code
|
361
|
| Rate for Payer: Cash Price |
$1,018.19
|
|
|
APICOECTOMY/PERIRADICULAR SURG-BI
|
Facility
|
OP
|
$400.00
|
|
|
Service Code
|
HCPCS D3421
|
| Hospital Charge Code |
42300775
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$200.00 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$220.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,018.19
|
| Rate for Payer: Aetna Government |
$1,018.19
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$712.73
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$712.73
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$712.73
|
| Rate for Payer: Brighton Health Commercial |
$300.00
|
| Rate for Payer: Cash Price |
$1,018.19
|
| Rate for Payer: Cash Price |
$1,018.19
|
| Rate for Payer: Cash Price |
$1,018.19
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,018.19
|
| 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 |
$1,018.19
|
| Rate for Payer: EmblemHealth Commercial |
$1,018.19
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$865.46
|
| Rate for Payer: Fidelis Essential Plan QHP |
$906.19
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,018.19
|
| Rate for Payer: Fidelis Qualified Health Plan |
$906.19
|
| Rate for Payer: Group Health Inc Commercial |
$1,018.19
|
| Rate for Payer: Group Health Inc Medicare |
$1,018.19
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$200.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,018.19
|
| Rate for Payer: Healthfirst Medicare Advantage |
$865.46
|
| Rate for Payer: Healthfirst QHP |
$1,018.19
|
| Rate for Payer: Humana Medicare |
$1,038.55
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,018.19
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,018.19
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,018.19
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$814.55
|
| Rate for Payer: Wellcare Medicare |
$967.28
|
|
|
APICOECTOMY/PERIRADICULAR SURG (E
|
Facility
|
OP
|
$150.00
|
|
|
Service Code
|
HCPCS D3426
|
| Hospital Charge Code |
42300785
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$52.50 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$82.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$89.95
|
| Rate for Payer: Aetna Government |
$89.95
|
| Rate for Payer: Brighton Health Commercial |
$112.50
|
| 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: Group Health Inc Commercial |
$75.00
|
| Rate for Payer: Group Health Inc Medicare |
$52.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$75.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$75.00
|
|
|
APICOECTOMY/PERIRADICULAR SURGERY
|
Facility
|
IP
|
$400.00
|
|
|
Service Code
|
HCPCS D3410
|
| Hospital Charge Code |
42300765
|
|
Hospital Revenue Code
|
361
|
| Rate for Payer: Cash Price |
$1,018.19
|
|
|
APICOECTOMY/PERIRADICULAR SURGERY
|
Facility
|
OP
|
$400.00
|
|
|
Service Code
|
HCPCS D3410
|
| Hospital Charge Code |
42300765
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$200.00 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$220.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,018.19
|
| Rate for Payer: Aetna Government |
$1,018.19
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$712.73
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$712.73
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$712.73
|
| Rate for Payer: Brighton Health Commercial |
$300.00
|
| Rate for Payer: Cash Price |
$1,018.19
|
| Rate for Payer: Cash Price |
$1,018.19
|
| Rate for Payer: Cash Price |
$1,018.19
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,018.19
|
| 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 |
$1,018.19
|
| Rate for Payer: EmblemHealth Commercial |
$1,018.19
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$865.46
|
| Rate for Payer: Fidelis Essential Plan QHP |
$906.19
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,018.19
|
| Rate for Payer: Fidelis Qualified Health Plan |
$906.19
|
| Rate for Payer: Group Health Inc Commercial |
$1,018.19
|
| Rate for Payer: Group Health Inc Medicare |
$1,018.19
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$200.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,018.19
|
| Rate for Payer: Healthfirst Medicare Advantage |
$865.46
|
| Rate for Payer: Healthfirst QHP |
$1,018.19
|
| Rate for Payer: Humana Medicare |
$1,038.55
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,018.19
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,018.19
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,018.19
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$814.55
|
| Rate for Payer: Wellcare Medicare |
$967.28
|
|
|
APICOECTOMY/PERIRADICULAR SURG-MO
|
Facility
|
OP
|
$450.00
|
|
|
Service Code
|
HCPCS D3425
|
| Hospital Charge Code |
42300780
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$225.00 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$247.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,018.19
|
| Rate for Payer: Aetna Government |
$1,018.19
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$712.73
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$712.73
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$712.73
|
| Rate for Payer: Brighton Health Commercial |
$337.50
|
| Rate for Payer: Cash Price |
$1,018.19
|
| Rate for Payer: Cash Price |
$1,018.19
|
| Rate for Payer: Cash Price |
$1,018.19
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,018.19
|
| 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 |
$1,018.19
|
| Rate for Payer: EmblemHealth Commercial |
$1,018.19
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$865.46
|
| Rate for Payer: Fidelis Essential Plan QHP |
$906.19
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,018.19
|
| Rate for Payer: Fidelis Qualified Health Plan |
$906.19
|
| Rate for Payer: Group Health Inc Commercial |
$1,018.19
|
| Rate for Payer: Group Health Inc Medicare |
$1,018.19
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$225.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,018.19
|
| Rate for Payer: Healthfirst Medicare Advantage |
$865.46
|
| Rate for Payer: Healthfirst QHP |
$1,018.19
|
| Rate for Payer: Humana Medicare |
$1,038.55
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,018.19
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,018.19
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,018.19
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$814.55
|
| Rate for Payer: Wellcare Medicare |
$967.28
|
|
|
APICOECTOMY/PERIRADICULAR SURG-MO
|
Facility
|
IP
|
$450.00
|
|
|
Service Code
|
HCPCS D3425
|
| Hospital Charge Code |
42300780
|
|
Hospital Revenue Code
|
361
|
| Rate for Payer: Cash Price |
$1,018.19
|
|
|
APIXABAN 2.5 MG
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
HCPCS C9399
|
| Hospital Charge Code |
41645909
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.10 |
| Max. Negotiated Rate |
$4.80 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$3.30
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3.00
|
| Rate for Payer: Aetna Government |
$3.00
|
| Rate for Payer: Brighton Health Commercial |
$4.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$4.80
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$4.08
|
| Rate for Payer: Group Health Inc Commercial |
$3.00
|
| Rate for Payer: Group Health Inc Medicare |
$2.10
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$3.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$3.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3.90
|
|
|
APIXABAN 2.5MG
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
HCPCS C9399
|
| Hospital Charge Code |
41655909
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.10 |
| Max. Negotiated Rate |
$4.80 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$3.30
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3.00
|
| Rate for Payer: Aetna Government |
$3.00
|
| Rate for Payer: Brighton Health Commercial |
$4.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$4.80
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$4.08
|
| Rate for Payer: Group Health Inc Commercial |
$3.00
|
| Rate for Payer: Group Health Inc Medicare |
$2.10
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$3.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$3.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3.90
|
|
|
APIXABAN 2.5 MG PO TABS [119040]
|
Facility
|
OP
|
$11.89
|
|
|
Service Code
|
NDC 00003089331
|
| Hospital Charge Code |
00003089331
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.16 |
| Max. Negotiated Rate |
$9.51 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$6.54
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$5.94
|
| Rate for Payer: Aetna Government |
$5.94
|
| Rate for Payer: Brighton Health Commercial |
$8.92
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$9.51
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$8.08
|
| Rate for Payer: Group Health Inc Commercial |
$5.94
|
| Rate for Payer: Group Health Inc Medicare |
$4.16
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$5.94
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$5.94
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$7.73
|
|
|
APIXABAN 2.5 MG PO TABS [119040]
|
Facility
|
OP
|
$11.89
|
|
|
Service Code
|
NDC 00003089321
|
| Hospital Charge Code |
00003089321
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.16 |
| Max. Negotiated Rate |
$9.51 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$6.54
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$5.94
|
| Rate for Payer: Aetna Government |
$5.94
|
| Rate for Payer: Brighton Health Commercial |
$8.92
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$9.51
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$8.08
|
| Rate for Payer: Group Health Inc Commercial |
$5.94
|
| Rate for Payer: Group Health Inc Medicare |
$4.16
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$5.94
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$5.94
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$7.73
|
|
|
APIXABAN 5 MG PO TABS [119614]
|
Facility
|
OP
|
$11.89
|
|
|
Service Code
|
NDC 00003089431
|
| Hospital Charge Code |
00003089431
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.16 |
| Max. Negotiated Rate |
$9.51 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$6.54
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$5.94
|
| Rate for Payer: Aetna Government |
$5.94
|
| Rate for Payer: Brighton Health Commercial |
$8.92
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$9.51
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$8.08
|
| Rate for Payer: Group Health Inc Commercial |
$5.94
|
| Rate for Payer: Group Health Inc Medicare |
$4.16
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$5.94
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$5.94
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$7.73
|
|
|
APIXABAN 5 MG PO TABS [119614]
|
Facility
|
OP
|
$11.89
|
|
|
Service Code
|
NDC 00003089421
|
| Hospital Charge Code |
00003089421
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.16 |
| Max. Negotiated Rate |
$9.51 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$6.54
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$5.94
|
| Rate for Payer: Aetna Government |
$5.94
|
| Rate for Payer: Brighton Health Commercial |
$8.92
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$9.51
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$8.08
|
| Rate for Payer: Group Health Inc Commercial |
$5.94
|
| Rate for Payer: Group Health Inc Medicare |
$4.16
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$5.94
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$5.94
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$7.73
|
|
|
APIXABAN 5MG TAB
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
HCPCS C9399
|
| Hospital Charge Code |
41645911
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.10 |
| Max. Negotiated Rate |
$4.80 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$3.30
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3.00
|
| Rate for Payer: Aetna Government |
$3.00
|
| Rate for Payer: Brighton Health Commercial |
$4.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$4.80
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$4.08
|
| Rate for Payer: Group Health Inc Commercial |
$3.00
|
| Rate for Payer: Group Health Inc Medicare |
$2.10
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$3.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$3.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3.90
|
|
|
APIXABAN 5MG TAB
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
HCPCS C9399
|
| Hospital Charge Code |
41655911
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.10 |
| Max. Negotiated Rate |
$4.80 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$3.30
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3.00
|
| Rate for Payer: Aetna Government |
$3.00
|
| Rate for Payer: Brighton Health Commercial |
$4.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$4.80
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$4.08
|
| Rate for Payer: Group Health Inc Commercial |
$3.00
|
| Rate for Payer: Group Health Inc Medicare |
$2.10
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$3.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$3.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3.90
|
|
|
APLIGRAF LIVING CELL BASED PROD
|
Facility
|
OP
|
$597.50
|
|
|
Service Code
|
HCPCS Q4101
|
| Hospital Charge Code |
64904812
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$30.43 |
| Max. Negotiated Rate |
$388.38 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$328.62
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$30.43
|
| Rate for Payer: Aetna Government |
$30.43
|
| Rate for Payer: Brighton Health Commercial |
$358.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$298.75
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$343.56
|
| Rate for Payer: Group Health Inc Commercial |
$298.75
|
| Rate for Payer: Group Health Inc Medicare |
$209.12
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$298.75
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$298.75
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$32.46
|
| Rate for Payer: SOMOS Essential |
$32.46
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$388.38
|
|
|
APLIGRAF LIVING CELL BASED PROD
|
Facility
|
IP
|
$597.50
|
|
|
Service Code
|
HCPCS Q4101
|
| Hospital Charge Code |
64904812
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$298.75 |
| Max. Negotiated Rate |
$298.75 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$298.75
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$298.75
|
|
|
APLIGRAF PER SQ CM
|
Facility
|
OP
|
$65.18
|
|
|
Service Code
|
HCPCS Q4101
|
| Hospital Charge Code |
42500164
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.81 |
| Max. Negotiated Rate |
$42.37 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$35.85
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$30.43
|
| Rate for Payer: Aetna Government |
$30.43
|
| Rate for Payer: Brighton Health Commercial |
$39.11
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$32.59
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$37.48
|
| Rate for Payer: Group Health Inc Commercial |
$32.59
|
| Rate for Payer: Group Health Inc Medicare |
$22.81
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$32.59
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$32.59
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$32.46
|
| Rate for Payer: SOMOS Essential |
$32.46
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$42.37
|
|
|
APLIGRAF PER SQ CM
|
Facility
|
IP
|
$71.73
|
|
|
Service Code
|
HCPCS Q4101
|
| Hospital Charge Code |
40203091
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$35.86 |
| Max. Negotiated Rate |
$35.86 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$35.86
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$35.86
|
|
