|
PR OFFICE/OUTPATIENT ESTABLISHED HIGH MDM 40 MIN
|
Professional
|
Both
|
$582.23
|
|
|
Service Code
|
HCPCS 99215
|
| Min. Negotiated Rate |
$111.38 |
| Max. Negotiated Rate |
$562.54 |
| Rate for Payer: Amida Care Medicaid |
$562.54
|
| Rate for Payer: Cash Price |
$161.31
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$159.12
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$143.21
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$143.21
|
| Rate for Payer: Fidelis Essential Plan QHP |
$151.16
|
| Rate for Payer: Fidelis Medicare Advantage |
$159.12
|
| Rate for Payer: Fidelis Qualified Health Plan |
$151.16
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$159.12
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$159.12
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$119.34
|
| Rate for Payer: Healthfirst Commercial |
$159.12
|
| Rate for Payer: Healthfirst Essential Plan |
$358.02
|
| Rate for Payer: Healthfirst Medicare Advantage |
$151.16
|
| Rate for Payer: Healthfirst QHP |
$159.12
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$111.38
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$159.12
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$135.25
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$111.38
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$159.12
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$119.34
|
| Rate for Payer: SOMOS Essential |
$119.34
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$159.12
|
|
|
PR OFFICE/OUTPATIENT ESTABLISHED LOW MDM 20 MIN
|
Professional
|
Both
|
$269.26
|
|
|
Service Code
|
HCPCS 99213
|
| Min. Negotiated Rate |
$51.16 |
| Max. Negotiated Rate |
$164.45 |
| Rate for Payer: Amida Care Medicaid |
$134.50
|
| Rate for Payer: Cash Price |
$73.60
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$73.09
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$65.78
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$65.78
|
| Rate for Payer: Fidelis Essential Plan QHP |
$69.44
|
| Rate for Payer: Fidelis Medicare Advantage |
$73.09
|
| Rate for Payer: Fidelis Qualified Health Plan |
$69.44
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$73.09
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$73.09
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$54.82
|
| Rate for Payer: Healthfirst Commercial |
$73.09
|
| Rate for Payer: Healthfirst Essential Plan |
$164.45
|
| Rate for Payer: Healthfirst Medicare Advantage |
$69.44
|
| Rate for Payer: Healthfirst QHP |
$73.09
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$51.16
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$73.09
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$62.13
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$51.16
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$73.09
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$54.82
|
| Rate for Payer: SOMOS Essential |
$54.82
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$73.09
|
|
|
PR OFFICE/OUTPATIENT ESTABLISHED MOD MDM 30 MIN
|
Professional
|
Both
|
$396.66
|
|
|
Service Code
|
HCPCS 99214
|
| Min. Negotiated Rate |
$75.34 |
| Max. Negotiated Rate |
$287.87 |
| Rate for Payer: Amida Care Medicaid |
$287.87
|
| Rate for Payer: Cash Price |
$108.33
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$107.63
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$96.87
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$96.87
|
| Rate for Payer: Fidelis Essential Plan QHP |
$102.25
|
| Rate for Payer: Fidelis Medicare Advantage |
$107.63
|
| Rate for Payer: Fidelis Qualified Health Plan |
$102.25
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$107.63
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$107.63
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$80.72
|
| Rate for Payer: Healthfirst Commercial |
$107.63
|
| Rate for Payer: Healthfirst Essential Plan |
$242.17
|
| Rate for Payer: Healthfirst Medicare Advantage |
$102.25
|
| Rate for Payer: Healthfirst QHP |
$107.63
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$75.34
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$107.63
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$91.49
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$75.34
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$107.63
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$80.72
|
| Rate for Payer: SOMOS Essential |
$80.72
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$107.63
|
|
|
PR OFFICE/OUTPATIENT ESTABLISHED SF MDM 10 MIN
|
Professional
|
Both
|
$145.78
|
|
|
Service Code
|
HCPCS 99212
|
| Min. Negotiated Rate |
$11.47 |
| Max. Negotiated Rate |
$87.41 |
| Rate for Payer: Amida Care Medicaid |
$11.47
|
| Rate for Payer: Cash Price |
$39.56
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$38.85
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$34.97
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$34.97
|
| Rate for Payer: Fidelis Essential Plan QHP |
$36.91
|
| Rate for Payer: Fidelis Medicare Advantage |
$38.85
|
| Rate for Payer: Fidelis Qualified Health Plan |
$36.91
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$38.85
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$38.85
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$29.14
|
| Rate for Payer: Healthfirst Commercial |
$38.85
|
| Rate for Payer: Healthfirst Essential Plan |
$87.41
|
| Rate for Payer: Healthfirst Medicare Advantage |
$36.91
|
| Rate for Payer: Healthfirst QHP |
$38.85
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$27.20
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$38.85
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$33.02
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$27.20
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$38.85
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$29.14
|
| Rate for Payer: SOMOS Essential |
$29.14
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$38.85
|
|
|
PR OFFICE/OUTPATIENT EST PT MAY NOT REQ PHYS/QHP
|
Professional
|
Both
|
$35.35
|
|
|
Service Code
|
HCPCS 99211
|
| Min. Negotiated Rate |
$4.36 |
| Max. Negotiated Rate |
$21.46 |
| Rate for Payer: Amida Care Medicaid |
$4.36
|
| Rate for Payer: Cash Price |
$9.65
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$9.54
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$8.59
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$8.59
|
| Rate for Payer: Fidelis Essential Plan QHP |
$9.06
|
| Rate for Payer: Fidelis Medicare Advantage |
$9.54
|
| Rate for Payer: Fidelis Qualified Health Plan |
$9.06
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$9.54
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$9.54
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$7.16
|
| Rate for Payer: Healthfirst Commercial |
$9.54
|
| Rate for Payer: Healthfirst Essential Plan |
$21.46
|
| Rate for Payer: Healthfirst Medicare Advantage |
$9.06
|
| Rate for Payer: Healthfirst QHP |
$9.54
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$6.68
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$9.54
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$8.11
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$6.68
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$9.54
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$7.16
|
| Rate for Payer: SOMOS Essential |
$7.16
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$9.54
|
|
|
PR OFFICE/OUTPATIENT NEW HIGH MDM 60 MINUTES
|
Professional
|
Both
|
$744.56
|
|
|
Service Code
|
HCPCS 99205
|
| Min. Negotiated Rate |
$142.32 |
| Max. Negotiated Rate |
$562.54 |
| Rate for Payer: Amida Care Medicaid |
$562.54
|
| Rate for Payer: Cash Price |
$204.39
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$203.31
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$182.98
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$182.98
|
| Rate for Payer: Fidelis Essential Plan QHP |
$193.14
|
| Rate for Payer: Fidelis Medicare Advantage |
$203.31
|
| Rate for Payer: Fidelis Qualified Health Plan |
$193.14
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$203.31
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$203.31
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$152.48
|
| Rate for Payer: Healthfirst Commercial |
$203.31
|
| Rate for Payer: Healthfirst Essential Plan |
$457.45
|
| Rate for Payer: Healthfirst Medicare Advantage |
$193.14
|
| Rate for Payer: Healthfirst QHP |
$203.31
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$142.32
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$203.31
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$172.81
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$142.32
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$203.31
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$152.48
|
| Rate for Payer: SOMOS Essential |
$152.48
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$203.31
|
|
|
PR OFFICE/OUTPATIENT NEW LOW MDM 30 MINUTES
|
Professional
|
Both
|
$344.65
|
|
|
Service Code
|
HCPCS 99203
|
| Min. Negotiated Rate |
$34.04 |
| Max. Negotiated Rate |
$206.53 |
| Rate for Payer: Amida Care Medicaid |
$34.04
|
| Rate for Payer: Cash Price |
$92.53
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$91.79
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$82.61
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$82.61
|
| Rate for Payer: Fidelis Essential Plan QHP |
$87.20
|
| Rate for Payer: Fidelis Medicare Advantage |
$91.79
|
| Rate for Payer: Fidelis Qualified Health Plan |
$87.20
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$91.79
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$91.79
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$68.84
|
| Rate for Payer: Healthfirst Commercial |
$91.79
|
| Rate for Payer: Healthfirst Essential Plan |
$206.53
|
| Rate for Payer: Healthfirst Medicare Advantage |
$87.20
|
| Rate for Payer: Healthfirst QHP |
$91.79
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$64.25
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$91.79
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$78.02
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$64.25
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$91.79
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$68.84
|
| Rate for Payer: SOMOS Essential |
$68.84
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$91.79
|
|
|
PR OFFICE/OUTPATIENT NEW MODERATE MDM 45 MINUTES
|
Professional
|
Both
|
$548.14
|
|
|
Service Code
|
HCPCS 99204
|
| Min. Negotiated Rate |
$56.57 |
| Max. Negotiated Rate |
$335.34 |
| Rate for Payer: Amida Care Medicaid |
$56.57
|
| Rate for Payer: Cash Price |
$150.09
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$149.04
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$134.14
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$134.14
|
| Rate for Payer: Fidelis Essential Plan QHP |
$141.59
|
| Rate for Payer: Fidelis Medicare Advantage |
$149.04
|
| Rate for Payer: Fidelis Qualified Health Plan |
$141.59
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$149.04
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$149.04
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$111.78
|
| Rate for Payer: Healthfirst Commercial |
$149.04
|
| Rate for Payer: Healthfirst Essential Plan |
$335.34
|
| Rate for Payer: Healthfirst Medicare Advantage |
$141.59
|
| Rate for Payer: Healthfirst QHP |
$149.04
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$104.33
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$149.04
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$126.68
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$104.33
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$149.04
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$111.78
|
| Rate for Payer: SOMOS Essential |
$111.78
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$149.04
|
|
|
PR OFFICE/OUTPATIENT NEW SF MDM 15 MINUTES
|
Professional
|
Both
|
$197.30
|
|
|
Service Code
|
HCPCS 99202
|
| Min. Negotiated Rate |
$22.18 |
| Max. Negotiated Rate |
$116.75 |
| Rate for Payer: Amida Care Medicaid |
$22.18
|
| Rate for Payer: Cash Price |
$53.15
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$51.89
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$46.70
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$46.70
|
| Rate for Payer: Fidelis Essential Plan QHP |
$49.30
|
| Rate for Payer: Fidelis Medicare Advantage |
$51.89
|
| Rate for Payer: Fidelis Qualified Health Plan |
$49.30
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$51.89
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$51.89
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$38.92
|
| Rate for Payer: Healthfirst Commercial |
$51.89
|
| Rate for Payer: Healthfirst Essential Plan |
$116.75
|
| Rate for Payer: Healthfirst Medicare Advantage |
$49.30
|
| Rate for Payer: Healthfirst QHP |
$51.89
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$36.32
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$51.89
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$44.11
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$36.32
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$51.89
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$38.92
|
| Rate for Payer: SOMOS Essential |
$38.92
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$51.89
|
|
|
PROGESTERONE 8 % VA GEL
|
Facility
|
OP
|
$31.87
|
|
|
Service Code
|
NDC 0023615108
|
| Hospital Charge Code |
0023615108
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.16 |
| Max. Negotiated Rate |
$25.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$17.53
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$15.94
|
| Rate for Payer: Aetna Government |
$15.94
|
| Rate for Payer: Brighton Health Commercial |
$23.90
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$25.50
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$21.67
|
| Rate for Payer: EmblemHealth Commercial |
$15.94
|
| Rate for Payer: Group Health Inc Commercial |
$15.94
|
| Rate for Payer: Group Health Inc Medicare |
$11.16
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$15.94
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$15.94
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$20.72
|
|
|
PROGESTERONE 8 % VA GEL
|
Facility
|
IP
|
$31.87
|
|
|
Service Code
|
NDC 0023615108
|
| Hospital Charge Code |
0023615108
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.94 |
| Max. Negotiated Rate |
$15.94 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$15.94
|
|
|
PR OMALIZUMAB INJECTION
|
Professional
|
Both
|
$95.00
|
|
|
Service Code
|
HCPCS J2357
|
| Min. Negotiated Rate |
$31.22 |
| Max. Negotiated Rate |
$100.35 |
| Rate for Payer: Cash Price |
$36.81
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$44.60
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$40.14
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$40.14
|
| Rate for Payer: Fidelis Essential Plan QHP |
$42.37
|
| Rate for Payer: Fidelis Medicare Advantage |
$44.60
|
| Rate for Payer: Fidelis Qualified Health Plan |
$42.37
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$44.60
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$44.60
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$33.45
|
| Rate for Payer: Healthfirst Commercial |
$44.60
|
| Rate for Payer: Healthfirst Essential Plan |
$100.35
|
| Rate for Payer: Healthfirst Medicare Advantage |
$42.37
|
| Rate for Payer: Healthfirst QHP |
$44.60
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$31.22
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$44.60
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$37.91
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$31.22
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$44.60
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$33.45
|
| Rate for Payer: SOMOS Essential |
$33.45
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$44.60
|
|
|
PR OMENTAL FLAP EXTRA-ABDOMINAL
|
Professional
|
Both
|
$6,169.73
|
|
|
Service Code
|
HCPCS 49904
|
| Min. Negotiated Rate |
$1,145.69 |
| Max. Negotiated Rate |
$3,682.57 |
| Rate for Payer: Cash Price |
$1,655.43
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,636.70
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$1,473.03
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$1,473.03
|
| Rate for Payer: Fidelis Essential Plan QHP |
$1,554.87
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,636.70
|
| Rate for Payer: Fidelis Qualified Health Plan |
$1,554.87
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,636.70
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,636.70
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$1,227.53
|
| Rate for Payer: Healthfirst Commercial |
$1,636.70
|
| Rate for Payer: Healthfirst Essential Plan |
$3,682.57
|
| Rate for Payer: Healthfirst Medicare Advantage |
$1,554.87
|
| Rate for Payer: Healthfirst QHP |
$1,636.70
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$1,145.69
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$1,636.70
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$1,391.19
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$1,145.69
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,636.70
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$1,227.53
|
| Rate for Payer: SOMOS Essential |
$1,227.53
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,636.70
|
|
|
PR OMENTAL FLAP INTRA-ABDOMINAL
|
Professional
|
Both
|
$1,573.39
|
|
|
Service Code
|
HCPCS 49905
|
| Min. Negotiated Rate |
$288.70 |
| Max. Negotiated Rate |
$927.97 |
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$412.43
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$371.19
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$371.19
|
| Rate for Payer: Fidelis Essential Plan QHP |
$391.81
|
| Rate for Payer: Fidelis Medicare Advantage |
$412.43
|
| Rate for Payer: Fidelis Qualified Health Plan |
$391.81
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$412.43
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$412.43
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$309.32
|
| Rate for Payer: Healthfirst Commercial |
$412.43
|
| Rate for Payer: Healthfirst Essential Plan |
$927.97
|
| Rate for Payer: Healthfirst Medicare Advantage |
$391.81
|
| Rate for Payer: Healthfirst QHP |
$412.43
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$288.70
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$412.43
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$350.57
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$288.70
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$412.43
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$309.32
|
| Rate for Payer: SOMOS Essential |
$309.32
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$412.43
|
|
|
PROMETHAZINE HCL 25 MG/ML IJ SOLN
|
Facility
|
OP
|
$2.22
|
|
|
Service Code
|
HCPCS J2550
|
| Hospital Charge Code |
0641149535
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.78 |
| Max. Negotiated Rate |
$2.95 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.22
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.37
|
| Rate for Payer: Aetna Government |
$2.37
|
| Rate for Payer: Brighton Health Commercial |
$1.66
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.77
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.51
|
| Rate for Payer: EmblemHealth Commercial |
$1.11
|
| Rate for Payer: Group Health Inc Commercial |
$1.11
|
| Rate for Payer: Group Health Inc Medicare |
$0.78
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.11
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.11
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$2.95
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.44
|
|
|
PROMETHAZINE HCL 25 MG/ML IJ SOLN
|
Facility
|
IP
|
$2.22
|
|
|
Service Code
|
HCPCS J2550
|
| Hospital Charge Code |
0641149535
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.11 |
| Max. Negotiated Rate |
$1.11 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.11
|
|
|
PROMETHAZINE HCL 25 MG/ML IJ SOLN
|
Facility
|
OP
|
$2.22
|
|
|
Service Code
|
HCPCS J2550
|
| Hospital Charge Code |
0641092825
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.78 |
| Max. Negotiated Rate |
$2.95 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.22
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.37
|
| Rate for Payer: Aetna Government |
$2.37
|
| Rate for Payer: Brighton Health Commercial |
$1.66
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.77
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.51
|
| Rate for Payer: EmblemHealth Commercial |
$1.11
|
| Rate for Payer: Group Health Inc Commercial |
$1.11
|
| Rate for Payer: Group Health Inc Medicare |
$0.78
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.11
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.11
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$2.95
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.44
|
|
|
PROMETHAZINE HCL 25 MG/ML IJ SOLN
|
Facility
|
IP
|
$2.50
|
|
|
Service Code
|
HCPCS J2550
|
| Hospital Charge Code |
3982255252
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.25 |
| Max. Negotiated Rate |
$1.25 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.25
|
|
|
PROMETHAZINE HCL 25 MG/ML IJ SOLN
|
Facility
|
OP
|
$2.50
|
|
|
Service Code
|
HCPCS J2550
|
| Hospital Charge Code |
3982255252
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.88 |
| Max. Negotiated Rate |
$2.95 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.38
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.37
|
| Rate for Payer: Aetna Government |
$2.37
|
| Rate for Payer: Brighton Health Commercial |
$1.88
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.70
|
| Rate for Payer: EmblemHealth Commercial |
$1.25
|
| Rate for Payer: Group Health Inc Commercial |
$1.25
|
| Rate for Payer: Group Health Inc Medicare |
$0.88
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.25
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.25
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$2.95
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.62
|
|
|
PROMETHAZINE HCL 25 MG/ML IJ SOLN
|
Facility
|
IP
|
$2.50
|
|
|
Service Code
|
HCPCS J2550
|
| Hospital Charge Code |
3982255253
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.25 |
| Max. Negotiated Rate |
$1.25 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.25
|
|
|
PROMETHAZINE HCL 25 MG/ML IJ SOLN
|
Facility
|
OP
|
$2.50
|
|
|
Service Code
|
HCPCS J2550
|
| Hospital Charge Code |
3982255253
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.88 |
| Max. Negotiated Rate |
$2.95 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.38
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.37
|
| Rate for Payer: Aetna Government |
$2.37
|
| Rate for Payer: Brighton Health Commercial |
$1.88
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.70
|
| Rate for Payer: EmblemHealth Commercial |
$1.25
|
| Rate for Payer: Group Health Inc Commercial |
$1.25
|
| Rate for Payer: Group Health Inc Medicare |
$0.88
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.25
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.25
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$2.95
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.62
|
|
|
PROMETHAZINE HCL 25 MG/ML IJ SOLN
|
Facility
|
IP
|
$2.22
|
|
|
Service Code
|
HCPCS J2550
|
| Hospital Charge Code |
0641092825
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.11 |
| Max. Negotiated Rate |
$1.11 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.11
|
|
|
PROMETHAZINE HCL 25 MG PO TABS
|
Facility
|
IP
|
$0.95
|
|
|
Service Code
|
HCPCS Q0169
|
| Hospital Charge Code |
0904646161
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.48 |
| Max. Negotiated Rate |
$0.48 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.48
|
|
|
PROMETHAZINE HCL 25 MG PO TABS
|
Facility
|
OP
|
$0.95
|
|
|
Service Code
|
HCPCS Q0169
|
| Hospital Charge Code |
0904646161
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.76 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.52
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.08
|
| Rate for Payer: Aetna Government |
$0.08
|
| Rate for Payer: Brighton Health Commercial |
$0.71
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.76
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.65
|
| Rate for Payer: EmblemHealth Commercial |
$0.48
|
| Rate for Payer: Group Health Inc Commercial |
$0.48
|
| Rate for Payer: Group Health Inc Medicare |
$0.33
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.48
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.48
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.62
|
|
|
PROMETHAZINE HCL 25 MG RE SUPP
|
Facility
|
OP
|
$17.71
|
|
|
Service Code
|
NDC 0713052612
|
| Hospital Charge Code |
0713052612
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.20 |
| Max. Negotiated Rate |
$14.16 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$9.74
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$8.85
|
| Rate for Payer: Aetna Government |
$8.85
|
| Rate for Payer: Brighton Health Commercial |
$13.28
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$14.16
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$12.04
|
| Rate for Payer: EmblemHealth Commercial |
$8.85
|
| Rate for Payer: Group Health Inc Commercial |
$8.85
|
| Rate for Payer: Group Health Inc Medicare |
$6.20
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$8.85
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$8.85
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$11.51
|
|
