|
Shoulder, upper arm & forearm procedures except joint replacement
|
Facility
|
IP
|
$46,239.64
|
|
|
Service Code
|
APR-DRG 3151
|
| Min. Negotiated Rate |
$10,191.00 |
| Max. Negotiated Rate |
$46,239.64 |
| Rate for Payer: Affinity Essential Plan 1&2 |
$46,239.64
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$46,239.64
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$20,550.95
|
| Rate for Payer: Amida Care Medicaid |
$20,550.95
|
| Rate for Payer: EmblemHealth Essential Plan 1&2 |
$46,239.64
|
| Rate for Payer: EmblemHealth Essential Plan 3&4 |
$20,550.95
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$20,550.95
|
| Rate for Payer: Fidelis Qualified Health Plan |
$24,661.14
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$20,550.95
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$20,550.95
|
| Rate for Payer: Healthfirst Commercial |
$16,719.00
|
| Rate for Payer: Healthfirst Essential Plan |
$46,239.64
|
| Rate for Payer: Healthfirst QHP |
$10,191.00
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$20,550.95
|
| Rate for Payer: SOMOS Essential |
$46,239.64
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$46,239.64
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$46,239.64
|
| Rate for Payer: United Healthcare Medicaid |
$20,550.95
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$20,550.95
|
|
|
Shoulder, upper arm & forearm procedures except joint replacement
|
Facility
|
IP
|
$56,340.14
|
|
|
Service Code
|
APR-DRG 3152
|
| Min. Negotiated Rate |
$15,848.00 |
| Max. Negotiated Rate |
$56,340.14 |
| Rate for Payer: Affinity Essential Plan 1&2 |
$56,340.14
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$56,340.14
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$25,040.06
|
| Rate for Payer: Amida Care Medicaid |
$25,040.06
|
| Rate for Payer: EmblemHealth Essential Plan 1&2 |
$56,340.14
|
| Rate for Payer: EmblemHealth Essential Plan 3&4 |
$25,040.06
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$25,040.06
|
| Rate for Payer: Fidelis Qualified Health Plan |
$30,048.07
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$25,040.06
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$25,040.06
|
| Rate for Payer: Healthfirst Commercial |
$27,169.00
|
| Rate for Payer: Healthfirst Essential Plan |
$56,340.14
|
| Rate for Payer: Healthfirst QHP |
$15,848.00
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$25,040.06
|
| Rate for Payer: SOMOS Essential |
$56,340.14
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$56,340.14
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$56,340.14
|
| Rate for Payer: United Healthcare Medicaid |
$25,040.06
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$25,040.06
|
|
|
Shoulder, upper arm & forearm procedures except joint replacement
|
Facility
|
IP
|
$78,943.54
|
|
|
Service Code
|
APR-DRG 3153
|
| Min. Negotiated Rate |
$27,927.00 |
| Max. Negotiated Rate |
$78,943.54 |
| Rate for Payer: Affinity Essential Plan 1&2 |
$78,943.54
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$78,943.54
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$35,086.02
|
| Rate for Payer: Amida Care Medicaid |
$35,086.02
|
| Rate for Payer: EmblemHealth Essential Plan 1&2 |
$78,943.54
|
| Rate for Payer: EmblemHealth Essential Plan 3&4 |
$35,086.02
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$35,086.02
|
| Rate for Payer: Fidelis Qualified Health Plan |
$42,103.22
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$35,086.02
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$35,086.02
|
| Rate for Payer: Healthfirst Commercial |
$46,033.00
|
| Rate for Payer: Healthfirst Essential Plan |
$78,943.54
|
| Rate for Payer: Healthfirst QHP |
$27,927.00
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$35,086.02
|
| Rate for Payer: SOMOS Essential |
$78,943.54
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$78,943.54
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$78,943.54
|
| Rate for Payer: United Healthcare Medicaid |
$35,086.02
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$35,086.02
|
|
|
Shoulder, upper arm & forearm procedures except joint replacement
|
Facility
|
IP
|
$122,300.15
|
|
|
Service Code
|
APR-DRG 3154
|
| Min. Negotiated Rate |
$54,355.62 |
| Max. Negotiated Rate |
$122,300.15 |
| Rate for Payer: Affinity Essential Plan 1&2 |
$122,300.15
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$122,300.15
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$54,355.62
|
| Rate for Payer: Amida Care Medicaid |
$54,355.62
|
| Rate for Payer: EmblemHealth Essential Plan 1&2 |
$122,300.15
|
| Rate for Payer: EmblemHealth Essential Plan 3&4 |
$54,355.62
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$54,355.62
|
| Rate for Payer: Fidelis Qualified Health Plan |
$65,226.74
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$54,355.62
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$54,355.62
|
| Rate for Payer: Healthfirst Commercial |
$84,667.00
|
| Rate for Payer: Healthfirst Essential Plan |
$122,300.15
|
| Rate for Payer: Healthfirst QHP |
$56,985.00
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$54,355.62
|
| Rate for Payer: SOMOS Essential |
$122,300.15
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$122,300.15
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$122,300.15
|
| Rate for Payer: United Healthcare Medicaid |
$54,355.62
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$54,355.62
|
|
|
Sickle cell anemia crisis
|
Facility
|
IP
|
$43,779.17
|
|
|
Service Code
|
APR-DRG 6621
|
| Min. Negotiated Rate |
$7,512.00 |
| Max. Negotiated Rate |
$43,779.17 |
| Rate for Payer: Affinity Essential Plan 1&2 |
$43,779.17
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$43,779.17
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$19,457.41
|
| Rate for Payer: Amida Care Medicaid |
$19,457.41
|
| Rate for Payer: EmblemHealth Essential Plan 1&2 |
$43,779.17
|
| Rate for Payer: EmblemHealth Essential Plan 3&4 |
$19,457.41
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$19,457.41
|
| Rate for Payer: Fidelis Qualified Health Plan |
$23,348.89
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$19,457.41
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$19,457.41
|
| Rate for Payer: Healthfirst Commercial |
$12,145.00
|
| Rate for Payer: Healthfirst Essential Plan |
$43,779.17
|
| Rate for Payer: Healthfirst QHP |
$7,512.00
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$19,457.41
|
| Rate for Payer: SOMOS Essential |
$43,779.17
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$43,779.17
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$43,779.17
|
| Rate for Payer: United Healthcare Medicaid |
$19,457.41
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$19,457.41
|
|
|
Sickle cell anemia crisis
|
Facility
|
IP
|
$48,992.08
|
|
|
Service Code
|
APR-DRG 6622
|
| Min. Negotiated Rate |
$9,690.00 |
| Max. Negotiated Rate |
$48,992.08 |
| Rate for Payer: Affinity Essential Plan 1&2 |
$48,992.08
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$48,992.08
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$21,774.26
|
| Rate for Payer: Amida Care Medicaid |
$21,774.26
|
| Rate for Payer: EmblemHealth Essential Plan 1&2 |
$48,992.08
|
| Rate for Payer: EmblemHealth Essential Plan 3&4 |
$21,774.26
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$21,774.26
|
| Rate for Payer: Fidelis Qualified Health Plan |
$26,129.11
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$21,774.26
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$21,774.26
|
| Rate for Payer: Healthfirst Commercial |
$15,828.00
|
| Rate for Payer: Healthfirst Essential Plan |
$48,992.08
|
| Rate for Payer: Healthfirst QHP |
$9,690.00
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$21,774.26
|
| Rate for Payer: SOMOS Essential |
$48,992.08
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$48,992.08
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$48,992.08
|
| Rate for Payer: United Healthcare Medicaid |
$21,774.26
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$21,774.26
|
|
|
Sickle cell anemia crisis
|
Facility
|
IP
|
$59,113.67
|
|
|
Service Code
|
APR-DRG 6623
|
| Min. Negotiated Rate |
$14,527.00 |
| Max. Negotiated Rate |
$59,113.67 |
| Rate for Payer: Affinity Essential Plan 1&2 |
$59,113.67
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$59,113.67
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$26,272.74
|
| Rate for Payer: Amida Care Medicaid |
$26,272.74
|
| Rate for Payer: EmblemHealth Essential Plan 1&2 |
$59,113.67
|
| Rate for Payer: EmblemHealth Essential Plan 3&4 |
$26,272.74
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$26,272.74
|
| Rate for Payer: Fidelis Qualified Health Plan |
$31,527.29
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$26,272.74
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$26,272.74
|
| Rate for Payer: Healthfirst Commercial |
$25,448.00
|
| Rate for Payer: Healthfirst Essential Plan |
$59,113.67
|
| Rate for Payer: Healthfirst QHP |
$14,527.00
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$26,272.74
|
| Rate for Payer: SOMOS Essential |
$59,113.67
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$59,113.67
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$59,113.67
|
| Rate for Payer: United Healthcare Medicaid |
$26,272.74
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$26,272.74
|
|
|
Sickle cell anemia crisis
|
Facility
|
IP
|
$90,271.62
|
|
|
Service Code
|
APR-DRG 6624
|
| Min. Negotiated Rate |
$33,284.00 |
| Max. Negotiated Rate |
$90,271.62 |
| Rate for Payer: Affinity Essential Plan 1&2 |
$90,271.62
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$90,271.62
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$40,120.72
|
| Rate for Payer: Amida Care Medicaid |
$40,120.72
|
| Rate for Payer: EmblemHealth Essential Plan 1&2 |
$90,271.62
|
| Rate for Payer: EmblemHealth Essential Plan 3&4 |
$40,120.72
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$40,120.72
|
| Rate for Payer: Fidelis Qualified Health Plan |
$48,144.86
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$40,120.72
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$40,120.72
|
| Rate for Payer: Healthfirst Commercial |
$55,164.00
|
| Rate for Payer: Healthfirst Essential Plan |
$90,271.62
|
| Rate for Payer: Healthfirst QHP |
$33,284.00
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$40,120.72
|
| Rate for Payer: SOMOS Essential |
$90,271.62
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$90,271.62
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$90,271.62
|
| Rate for Payer: United Healthcare Medicaid |
$40,120.72
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$40,120.72
|
|
|
SICKLE CELL ANEMIA CRISIS
|
Facility
|
OP
|
$555.01
|
|
|
Service Code
|
EAPG 00783
|
| Min. Negotiated Rate |
$402.69 |
| Max. Negotiated Rate |
$555.01 |
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$402.69
|
| Rate for Payer: Healthfirst Commercial |
$555.01
|
|
|
SIGNS, SYMPTOMS AND OTHER FACTORS INFLUENCING HEALTH STATUS
|
Facility
|
OP
|
$222.15
|
|
|
Service Code
|
EAPG 00871
|
| Min. Negotiated Rate |
$162.00 |
| Max. Negotiated Rate |
$222.15 |
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$162.00
|
| Rate for Payer: Healthfirst Commercial |
$222.15
|
|
|
Signs, symptoms & other factors influencing health status
|
Facility
|
IP
|
$39,934.55
|
|
|
Service Code
|
APR-DRG 8611
|
| Min. Negotiated Rate |
$5,052.00 |
| Max. Negotiated Rate |
$39,934.55 |
| Rate for Payer: Affinity Essential Plan 1&2 |
$39,934.55
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$39,934.55
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$17,748.69
|
| Rate for Payer: Amida Care Medicaid |
$17,748.69
|
| Rate for Payer: EmblemHealth Essential Plan 1&2 |
$39,934.55
|
| Rate for Payer: EmblemHealth Essential Plan 3&4 |
$17,748.69
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$17,748.69
|
| Rate for Payer: Fidelis Qualified Health Plan |
$21,298.43
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$17,748.69
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$17,748.69
|
| Rate for Payer: Healthfirst Commercial |
$8,915.00
|
| Rate for Payer: Healthfirst Essential Plan |
$39,934.55
|
| Rate for Payer: Healthfirst QHP |
$5,052.00
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$17,748.69
|
| Rate for Payer: SOMOS Essential |
$39,934.55
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$39,934.55
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$39,934.55
|
| Rate for Payer: United Healthcare Medicaid |
$17,748.69
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$17,748.69
|
|
|
Signs, symptoms & other factors influencing health status
|
Facility
|
IP
|
$43,102.04
|
|
|
Service Code
|
APR-DRG 8612
|
| Min. Negotiated Rate |
$6,850.00 |
| Max. Negotiated Rate |
$43,102.04 |
| Rate for Payer: Affinity Essential Plan 1&2 |
$43,102.04
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$43,102.04
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$19,156.46
|
| Rate for Payer: Amida Care Medicaid |
$19,156.46
|
| Rate for Payer: EmblemHealth Essential Plan 1&2 |
$43,102.04
|
| Rate for Payer: EmblemHealth Essential Plan 3&4 |
$19,156.46
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$19,156.46
|
| Rate for Payer: Fidelis Qualified Health Plan |
$22,987.75
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$19,156.46
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$19,156.46
|
| Rate for Payer: Healthfirst Commercial |
$11,582.00
|
| Rate for Payer: Healthfirst Essential Plan |
$43,102.04
|
| Rate for Payer: Healthfirst QHP |
$6,850.00
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$19,156.46
|
| Rate for Payer: SOMOS Essential |
$43,102.04
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$43,102.04
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$43,102.04
|
| Rate for Payer: United Healthcare Medicaid |
$19,156.46
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$19,156.46
|
|
|
Signs, symptoms & other factors influencing health status
|
Facility
|
IP
|
$50,620.68
|
|
|
Service Code
|
APR-DRG 8613
|
| Min. Negotiated Rate |
$10,407.00 |
| Max. Negotiated Rate |
$50,620.68 |
| Rate for Payer: Affinity Essential Plan 1&2 |
$50,620.68
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$50,620.68
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$22,498.08
|
| Rate for Payer: Amida Care Medicaid |
$22,498.08
|
| Rate for Payer: EmblemHealth Essential Plan 1&2 |
$50,620.68
|
| Rate for Payer: EmblemHealth Essential Plan 3&4 |
$22,498.08
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$22,498.08
|
| Rate for Payer: Fidelis Qualified Health Plan |
$26,997.70
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$22,498.08
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$22,498.08
|
| Rate for Payer: Healthfirst Commercial |
$17,405.00
|
| Rate for Payer: Healthfirst Essential Plan |
$50,620.68
|
| Rate for Payer: Healthfirst QHP |
$10,407.00
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$22,498.08
|
| Rate for Payer: SOMOS Essential |
$50,620.68
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$50,620.68
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$50,620.68
|
| Rate for Payer: United Healthcare Medicaid |
$22,498.08
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$22,498.08
|
|
|
Signs, symptoms & other factors influencing health status
|
Facility
|
IP
|
$68,777.98
|
|
|
Service Code
|
APR-DRG 8614
|
| Min. Negotiated Rate |
$20,017.00 |
| Max. Negotiated Rate |
$68,777.98 |
| Rate for Payer: Affinity Essential Plan 1&2 |
$68,777.98
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$68,777.98
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$30,567.99
|
| Rate for Payer: Amida Care Medicaid |
$30,567.99
|
| Rate for Payer: EmblemHealth Essential Plan 1&2 |
$68,777.98
|
| Rate for Payer: EmblemHealth Essential Plan 3&4 |
$30,567.99
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$30,567.99
|
| Rate for Payer: Fidelis Qualified Health Plan |
$36,681.59
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$30,567.99
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$30,567.99
|
| Rate for Payer: Healthfirst Commercial |
$39,190.00
|
| Rate for Payer: Healthfirst Essential Plan |
$68,777.98
|
| Rate for Payer: Healthfirst QHP |
$20,017.00
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$30,567.99
|
| Rate for Payer: SOMOS Essential |
$68,777.98
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$68,777.98
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$68,777.98
|
| Rate for Payer: United Healthcare Medicaid |
$30,567.99
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$30,567.99
|
|
|
SILDENAFIL CITRATE 10 MG/12.5ML IV SOLN
|
Facility
|
OP
|
$17.60
|
|
|
Service Code
|
NDC 5515016613
|
| Hospital Charge Code |
5515016613
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$6.16 |
| Max. Negotiated Rate |
$14.08 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$9.68
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$8.80
|
| Rate for Payer: Aetna Government |
$8.80
|
| Rate for Payer: Brighton Health Commercial |
$13.20
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$14.08
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$11.97
|
| Rate for Payer: EmblemHealth Commercial |
$8.80
|
| Rate for Payer: Group Health Inc Commercial |
$8.80
|
| Rate for Payer: Group Health Inc Medicare |
$6.16
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$8.80
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$8.80
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$11.44
|
|
|
SILDENAFIL CITRATE 10 MG/12.5ML IV SOLN
|
Facility
|
IP
|
$17.60
|
|
|
Service Code
|
NDC 5515016613
|
| Hospital Charge Code |
5515016613
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$8.80 |
| Max. Negotiated Rate |
$8.80 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$8.80
|
|
|
SILDENAFIL CITRATE 20 MG PO TABS
|
Facility
|
IP
|
$1.40
|
|
|
Service Code
|
NDC 6068778811
|
| Hospital Charge Code |
6068778811
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.70 |
| Max. Negotiated Rate |
$0.70 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.70
|
|
|
SILDENAFIL CITRATE 20 MG PO TABS
|
Facility
|
OP
|
$1.39
|
|
|
Service Code
|
NDC 0904667104
|
| Hospital Charge Code |
0904667104
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.49 |
| Max. Negotiated Rate |
$1.12 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.77
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.70
|
| Rate for Payer: Aetna Government |
$0.70
|
| Rate for Payer: Brighton Health Commercial |
$1.05
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.12
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.95
|
| Rate for Payer: EmblemHealth Commercial |
$0.70
|
| Rate for Payer: Group Health Inc Commercial |
$0.70
|
| Rate for Payer: Group Health Inc Medicare |
$0.49
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.70
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.70
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.91
|
|
|
SILDENAFIL CITRATE 20 MG PO TABS
|
Facility
|
OP
|
$1.40
|
|
|
Service Code
|
NDC 6068778811
|
| Hospital Charge Code |
6068778811
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.49 |
| Max. Negotiated Rate |
$1.12 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.77
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.70
|
| Rate for Payer: Aetna Government |
$0.70
|
| Rate for Payer: Brighton Health Commercial |
$1.05
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.12
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.95
|
| Rate for Payer: EmblemHealth Commercial |
$0.70
|
| Rate for Payer: Group Health Inc Commercial |
$0.70
|
| Rate for Payer: Group Health Inc Medicare |
$0.49
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.70
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.70
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.91
|
|
|
SILDENAFIL CITRATE 20 MG PO TABS
|
Facility
|
IP
|
$20.00
|
|
|
Service Code
|
NDC 5976200331
|
| Hospital Charge Code |
5976200331
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.00 |
| Max. Negotiated Rate |
$10.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$10.00
|
|
|
SILDENAFIL CITRATE 20 MG PO TABS
|
Facility
|
OP
|
$20.00
|
|
|
Service Code
|
NDC 5976200331
|
| Hospital Charge Code |
5976200331
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.00 |
| Max. Negotiated Rate |
$16.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$11.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$10.00
|
| Rate for Payer: Aetna Government |
$10.00
|
| Rate for Payer: Brighton Health Commercial |
$15.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$16.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$13.60
|
| Rate for Payer: EmblemHealth Commercial |
$10.00
|
| Rate for Payer: Group Health Inc Commercial |
$10.00
|
| Rate for Payer: Group Health Inc Medicare |
$7.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$10.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$10.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$13.00
|
|
|
SILDENAFIL CITRATE 20 MG PO TABS
|
Facility
|
IP
|
$1.39
|
|
|
Service Code
|
NDC 0904667104
|
| Hospital Charge Code |
0904667104
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.70 |
| Max. Negotiated Rate |
$0.70 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.70
|
|
|
SILDENAFIL CITRATE 20 MG PO TABS
|
Facility
|
IP
|
$16.48
|
|
|
Service Code
|
NDC 5026871715
|
| Hospital Charge Code |
5026871715
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.24 |
| Max. Negotiated Rate |
$8.24 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$8.24
|
|
|
SILDENAFIL CITRATE 20 MG PO TABS
|
Facility
|
OP
|
$16.48
|
|
|
Service Code
|
NDC 5026871715
|
| Hospital Charge Code |
5026871715
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.77 |
| Max. Negotiated Rate |
$13.18 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$9.06
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$8.24
|
| Rate for Payer: Aetna Government |
$8.24
|
| Rate for Payer: Brighton Health Commercial |
$12.36
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$13.18
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$11.21
|
| Rate for Payer: EmblemHealth Commercial |
$8.24
|
| Rate for Payer: Group Health Inc Commercial |
$8.24
|
| Rate for Payer: Group Health Inc Medicare |
$5.77
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$8.24
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$8.24
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$10.71
|
|
|
SILVER NITRATE-POT NITRATE 75-25 % EX MISC
|
Facility
|
IP
|
$0.91
|
|
|
Service Code
|
NDC 1287000011
|
| Hospital Charge Code |
1287000011
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.45 |
| Max. Negotiated Rate |
$0.45 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.45
|
|
