|
TENECTEPLASE 50 MG IV KIT
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J3101
|
| Hospital Charge Code |
5024217601
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$4.40 |
| Max. Negotiated Rate |
$175.66 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$4.40
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$172.22
|
| Rate for Payer: Aetna Government |
$172.22
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$120.55
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$120.55
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$120.55
|
| Rate for Payer: Brighton Health Commercial |
$6.00
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$172.22
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$6.40
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$5.44
|
| Rate for Payer: Elderplan Medicare Advantage |
$172.22
|
| Rate for Payer: EmblemHealth Commercial |
$172.22
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$155.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$146.39
|
| Rate for Payer: Fidelis Essential Plan QHP |
$153.28
|
| Rate for Payer: Fidelis Medicare Advantage |
$172.22
|
| Rate for Payer: Fidelis Qualified Health Plan |
$153.28
|
| Rate for Payer: Group Health Inc Commercial |
$172.22
|
| Rate for Payer: Group Health Inc Medicare |
$172.22
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$172.22
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$172.22
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$172.22
|
| Rate for Payer: Healthfirst Medicare Advantage |
$146.39
|
| Rate for Payer: Healthfirst QHP |
$172.22
|
| Rate for Payer: Humana Medicare |
$175.66
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$172.22
|
| Rate for Payer: United Healthcare Medicare Advantage |
$172.22
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$5.20
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$163.61
|
| Rate for Payer: Wellcare Medicare |
$163.61
|
|
|
TENECTEPLASE 50 MG IV KIT (STEMI/PE)
|
Facility
|
IP
|
$9.00
|
|
|
Service Code
|
HCPCS J3101
|
| Hospital Charge Code |
5024212047
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$4.50 |
| Max. Negotiated Rate |
$4.50 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4.50
|
|
|
TENECTEPLASE 50 MG IV KIT (STEMI/PE)
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J3101
|
| Hospital Charge Code |
5024217601
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$4.40 |
| Max. Negotiated Rate |
$175.66 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$4.40
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$172.22
|
| Rate for Payer: Aetna Government |
$172.22
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$120.55
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$120.55
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$120.55
|
| Rate for Payer: Brighton Health Commercial |
$6.00
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$172.22
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$6.40
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$5.44
|
| Rate for Payer: Elderplan Medicare Advantage |
$172.22
|
| Rate for Payer: EmblemHealth Commercial |
$172.22
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$155.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$146.39
|
| Rate for Payer: Fidelis Essential Plan QHP |
$153.28
|
| Rate for Payer: Fidelis Medicare Advantage |
$172.22
|
| Rate for Payer: Fidelis Qualified Health Plan |
$153.28
|
| Rate for Payer: Group Health Inc Commercial |
$172.22
|
| Rate for Payer: Group Health Inc Medicare |
$172.22
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$172.22
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$172.22
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$172.22
|
| Rate for Payer: Healthfirst Medicare Advantage |
$146.39
|
| Rate for Payer: Healthfirst QHP |
$172.22
|
| Rate for Payer: Humana Medicare |
$175.66
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$172.22
|
| Rate for Payer: United Healthcare Medicare Advantage |
$172.22
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$5.20
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$163.61
|
| Rate for Payer: Wellcare Medicare |
$163.61
|
|
|
TENECTEPLASE 50 MG IV KIT (STEMI/PE)
|
Facility
|
OP
|
$9.00
|
|
|
Service Code
|
HCPCS J3101
|
| Hospital Charge Code |
5024212047
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$4.95 |
| Max. Negotiated Rate |
$175.66 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$4.95
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$172.22
|
| Rate for Payer: Aetna Government |
$172.22
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$120.55
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$120.55
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$120.55
|
| Rate for Payer: Brighton Health Commercial |
$6.75
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$172.22
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$7.20
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$6.12
|
| Rate for Payer: Elderplan Medicare Advantage |
$172.22
|
| Rate for Payer: EmblemHealth Commercial |
$172.22
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$155.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$146.39
|
| Rate for Payer: Fidelis Essential Plan QHP |
$153.28
|
| Rate for Payer: Fidelis Medicare Advantage |
$172.22
|
| Rate for Payer: Fidelis Qualified Health Plan |
$153.28
|
| Rate for Payer: Group Health Inc Commercial |
$172.22
|
| Rate for Payer: Group Health Inc Medicare |
$172.22
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$172.22
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$172.22
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$172.22
|
| Rate for Payer: Healthfirst Medicare Advantage |
$146.39
|
| Rate for Payer: Healthfirst QHP |
$172.22
|
| Rate for Payer: Humana Medicare |
$175.66
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$172.22
|
| Rate for Payer: United Healthcare Medicare Advantage |
$172.22
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$5.85
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$163.61
|
| Rate for Payer: Wellcare Medicare |
$163.61
|
|
|
TENECTEPLASE 50 MG IV KIT (STEMI/PE)
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J3101
|
| Hospital Charge Code |
5024217601
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$4.00 |
| Max. Negotiated Rate |
$4.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4.00
|
|
|
TENOFOVIR ALAFENAMIDE FUMARATE 25 MG PO TABS
|
Facility
|
IP
|
$57.66
|
|
|
Service Code
|
NDC 6195823011
|
| Hospital Charge Code |
6195823011
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$28.83 |
| Max. Negotiated Rate |
$28.83 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$28.83
|
|
|
TENOFOVIR ALAFENAMIDE FUMARATE 25 MG PO TABS
|
Facility
|
OP
|
$57.66
|
|
|
Service Code
|
NDC 6195823011
|
| Hospital Charge Code |
6195823011
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$20.18 |
| Max. Negotiated Rate |
$46.13 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$31.72
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$28.83
|
| Rate for Payer: Aetna Government |
$28.83
|
| Rate for Payer: Brighton Health Commercial |
$43.25
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$46.13
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$39.21
|
| Rate for Payer: EmblemHealth Commercial |
$28.83
|
| Rate for Payer: Group Health Inc Commercial |
$28.83
|
| Rate for Payer: Group Health Inc Medicare |
$20.18
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$28.83
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$28.83
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$37.48
|
|
|
TENOFOVIR DISOPROXIL FUMARATE 300 MG PO TABS
|
Facility
|
OP
|
$40.53
|
|
|
Service Code
|
NDC 3334209607
|
| Hospital Charge Code |
3334209607
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.19 |
| Max. Negotiated Rate |
$32.42 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$22.29
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$20.27
|
| Rate for Payer: Aetna Government |
$20.27
|
| Rate for Payer: Brighton Health Commercial |
$30.40
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$32.42
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$27.56
|
| Rate for Payer: EmblemHealth Commercial |
$20.27
|
| Rate for Payer: Group Health Inc Commercial |
$20.27
|
| Rate for Payer: Group Health Inc Medicare |
$14.19
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$20.27
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$20.27
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$26.35
|
|
|
TENOFOVIR DISOPROXIL FUMARATE 300 MG PO TABS
|
Facility
|
IP
|
$5.66
|
|
|
Service Code
|
NDC 0904682104
|
| Hospital Charge Code |
0904682104
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.83 |
| Max. Negotiated Rate |
$2.83 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.83
|
|
|
TENOFOVIR DISOPROXIL FUMARATE 300 MG PO TABS
|
Facility
|
IP
|
$40.53
|
|
|
Service Code
|
NDC 6438071404
|
| Hospital Charge Code |
6438071404
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$20.27 |
| Max. Negotiated Rate |
$20.27 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$20.27
|
|
|
TENOFOVIR DISOPROXIL FUMARATE 300 MG PO TABS
|
Facility
|
OP
|
$5.66
|
|
|
Service Code
|
NDC 0904682104
|
| Hospital Charge Code |
0904682104
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.98 |
| Max. Negotiated Rate |
$4.53 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$3.11
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.83
|
| Rate for Payer: Aetna Government |
$2.83
|
| Rate for Payer: Brighton Health Commercial |
$4.24
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$4.53
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$3.85
|
| Rate for Payer: EmblemHealth Commercial |
$2.83
|
| Rate for Payer: Group Health Inc Commercial |
$2.83
|
| Rate for Payer: Group Health Inc Medicare |
$1.98
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.83
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2.83
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3.68
|
|
|
TENOFOVIR DISOPROXIL FUMARATE 300 MG PO TABS
|
Facility
|
IP
|
$40.53
|
|
|
Service Code
|
NDC 3334209607
|
| Hospital Charge Code |
3334209607
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$20.27 |
| Max. Negotiated Rate |
$20.27 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$20.27
|
|
|
TENOFOVIR DISOPROXIL FUMARATE 300 MG PO TABS
|
Facility
|
OP
|
$40.53
|
|
|
Service Code
|
NDC 6438071404
|
| Hospital Charge Code |
6438071404
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.19 |
| Max. Negotiated Rate |
$32.42 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$22.29
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$20.27
|
| Rate for Payer: Aetna Government |
$20.27
|
| Rate for Payer: Brighton Health Commercial |
$30.40
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$32.42
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$27.56
|
| Rate for Payer: EmblemHealth Commercial |
$20.27
|
| Rate for Payer: Group Health Inc Commercial |
$20.27
|
| Rate for Payer: Group Health Inc Medicare |
$14.19
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$20.27
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$20.27
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$26.35
|
|
|
TENOFOVIR DISOPROXIL FUMARATE 300 MG PO TABS
|
Facility
|
IP
|
$5.57
|
|
|
Service Code
|
NDC 6909753302
|
| Hospital Charge Code |
6909753302
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.79 |
| Max. Negotiated Rate |
$2.79 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.79
|
|
|
TENOFOVIR DISOPROXIL FUMARATE 300 MG PO TABS
|
Facility
|
OP
|
$5.57
|
|
|
Service Code
|
NDC 6909753302
|
| Hospital Charge Code |
6909753302
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.95 |
| Max. Negotiated Rate |
$4.46 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$3.07
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.79
|
| Rate for Payer: Aetna Government |
$2.79
|
| Rate for Payer: Brighton Health Commercial |
$4.18
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$4.46
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$3.79
|
| Rate for Payer: EmblemHealth Commercial |
$2.79
|
| Rate for Payer: Group Health Inc Commercial |
$2.79
|
| Rate for Payer: Group Health Inc Medicare |
$1.95
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.79
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2.79
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3.62
|
|
|
TERBINAFINE HCL 250 MG PO TABS
|
Facility
|
OP
|
$13.02
|
|
|
Service Code
|
NDC 6909785902
|
| Hospital Charge Code |
6909785902
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.56 |
| Max. Negotiated Rate |
$10.42 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$7.16
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$6.51
|
| Rate for Payer: Aetna Government |
$6.51
|
| Rate for Payer: Brighton Health Commercial |
$9.77
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$10.42
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$8.86
|
| Rate for Payer: EmblemHealth Commercial |
$6.51
|
| Rate for Payer: Group Health Inc Commercial |
$6.51
|
| Rate for Payer: Group Health Inc Medicare |
$4.56
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$6.51
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$6.51
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$8.46
|
|
|
TERBINAFINE HCL 250 MG PO TABS
|
Facility
|
IP
|
$13.02
|
|
|
Service Code
|
NDC 6909773102
|
| Hospital Charge Code |
6909773102
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.51 |
| Max. Negotiated Rate |
$6.51 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$6.51
|
|
|
TERBINAFINE HCL 250 MG PO TABS
|
Facility
|
IP
|
$13.02
|
|
|
Service Code
|
NDC 6909785902
|
| Hospital Charge Code |
6909785902
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.51 |
| Max. Negotiated Rate |
$6.51 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$6.51
|
|
|
TERBINAFINE HCL 250 MG PO TABS
|
Facility
|
OP
|
$13.02
|
|
|
Service Code
|
NDC 6909773102
|
| Hospital Charge Code |
6909773102
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.56 |
| Max. Negotiated Rate |
$10.42 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$7.16
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$6.51
|
| Rate for Payer: Aetna Government |
$6.51
|
| Rate for Payer: Brighton Health Commercial |
$9.77
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$10.42
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$8.86
|
| Rate for Payer: EmblemHealth Commercial |
$6.51
|
| Rate for Payer: Group Health Inc Commercial |
$6.51
|
| Rate for Payer: Group Health Inc Medicare |
$4.56
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$6.51
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$6.51
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$8.46
|
|
|
TERBINAFINE HCL 250 MG PO TABS
|
Facility
|
OP
|
$12.79
|
|
|
Service Code
|
NDC 6586207930
|
| Hospital Charge Code |
6586207930
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.47 |
| Max. Negotiated Rate |
$10.23 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$7.03
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$6.39
|
| Rate for Payer: Aetna Government |
$6.39
|
| Rate for Payer: Brighton Health Commercial |
$9.59
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$10.23
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$8.69
|
| Rate for Payer: EmblemHealth Commercial |
$6.39
|
| Rate for Payer: Group Health Inc Commercial |
$6.39
|
| Rate for Payer: Group Health Inc Medicare |
$4.47
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$6.39
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$6.39
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$8.31
|
|
|
TERBINAFINE HCL 250 MG PO TABS
|
Facility
|
IP
|
$12.79
|
|
|
Service Code
|
NDC 6586207930
|
| Hospital Charge Code |
6586207930
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.39 |
| Max. Negotiated Rate |
$6.39 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$6.39
|
|
|
TERBUTALINE SULFATE 1 MG/ML IJ SOLN
|
Facility
|
OP
|
$4.80
|
|
|
Service Code
|
HCPCS J3105
|
| Hospital Charge Code |
0143974601
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.68 |
| Max. Negotiated Rate |
$7.39 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2.64
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.53
|
| Rate for Payer: Aetna Government |
$2.53
|
| Rate for Payer: Brighton Health Commercial |
$3.60
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$3.84
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$3.26
|
| Rate for Payer: EmblemHealth Commercial |
$2.40
|
| Rate for Payer: Group Health Inc Commercial |
$2.40
|
| Rate for Payer: Group Health Inc Medicare |
$1.68
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.40
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2.40
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$7.39
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3.12
|
|
|
TERBUTALINE SULFATE 1 MG/ML IJ SOLN
|
Facility
|
IP
|
$4.80
|
|
|
Service Code
|
HCPCS J3105
|
| Hospital Charge Code |
0143974610
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.40 |
| Max. Negotiated Rate |
$2.40 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.40
|
|
|
TERBUTALINE SULFATE 1 MG/ML IJ SOLN
|
Facility
|
OP
|
$4.80
|
|
|
Service Code
|
HCPCS J3105
|
| Hospital Charge Code |
0143974610
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.68 |
| Max. Negotiated Rate |
$7.39 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2.64
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.53
|
| Rate for Payer: Aetna Government |
$2.53
|
| Rate for Payer: Brighton Health Commercial |
$3.60
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$3.84
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$3.26
|
| Rate for Payer: EmblemHealth Commercial |
$2.40
|
| Rate for Payer: Group Health Inc Commercial |
$2.40
|
| Rate for Payer: Group Health Inc Medicare |
$1.68
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.40
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2.40
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$7.39
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3.12
|
|
|
TERBUTALINE SULFATE 1 MG/ML IJ SOLN
|
Facility
|
IP
|
$4.80
|
|
|
Service Code
|
HCPCS J3105
|
| Hospital Charge Code |
0143974601
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.40 |
| Max. Negotiated Rate |
$2.40 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.40
|
|
