|
VEDOLIZUMAB 300 MG IV SOLR
|
Facility
|
OP
|
$10.00
|
|
|
Service Code
|
HCPCS J3380
|
| Hospital Charge Code |
6476430020
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$5.50 |
| Max. Negotiated Rate |
$21.74 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$5.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$21.31
|
| Rate for Payer: Aetna Government |
$21.31
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$14.92
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$14.92
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$14.92
|
| Rate for Payer: Brighton Health Commercial |
$7.50
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$21.31
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$8.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$6.80
|
| Rate for Payer: Elderplan Medicare Advantage |
$21.31
|
| Rate for Payer: EmblemHealth Commercial |
$21.31
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$19.18
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$18.11
|
| Rate for Payer: Fidelis Essential Plan QHP |
$18.97
|
| Rate for Payer: Fidelis Medicare Advantage |
$21.31
|
| Rate for Payer: Fidelis Qualified Health Plan |
$18.97
|
| Rate for Payer: Group Health Inc Commercial |
$21.31
|
| Rate for Payer: Group Health Inc Medicare |
$21.31
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$21.31
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$21.31
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$21.31
|
| Rate for Payer: Healthfirst Medicare Advantage |
$18.11
|
| Rate for Payer: Healthfirst QHP |
$21.31
|
| Rate for Payer: Humana Medicare |
$21.74
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$21.31
|
| Rate for Payer: United Healthcare Medicare Advantage |
$21.31
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$6.50
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$20.24
|
| Rate for Payer: Wellcare Medicare |
$20.24
|
|
|
VEDOLIZUMAB 300 MG IV SOLR
|
Facility
|
IP
|
$10.00
|
|
|
Service Code
|
HCPCS J3380
|
| Hospital Charge Code |
6476430020
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$5.00 |
| Max. Negotiated Rate |
$5.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$5.00
|
|
|
VENLAFAXINE HCL ER 150 MG PO CP24
|
Facility
|
OP
|
$4.57
|
|
|
Service Code
|
NDC 6808471301
|
| Hospital Charge Code |
6808471301
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.60 |
| Max. Negotiated Rate |
$3.66 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2.51
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.29
|
| Rate for Payer: Aetna Government |
$2.29
|
| Rate for Payer: Brighton Health Commercial |
$3.43
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$3.66
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$3.11
|
| Rate for Payer: EmblemHealth Commercial |
$2.29
|
| Rate for Payer: Group Health Inc Commercial |
$2.29
|
| Rate for Payer: Group Health Inc Medicare |
$1.60
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.29
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2.29
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2.97
|
|
|
VENLAFAXINE HCL ER 150 MG PO CP24
|
Facility
|
OP
|
$5.08
|
|
|
Service Code
|
NDC 6586269705
|
| Hospital Charge Code |
6586269705
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.78 |
| Max. Negotiated Rate |
$4.07 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2.80
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.54
|
| Rate for Payer: Aetna Government |
$2.54
|
| Rate for Payer: Brighton Health Commercial |
$3.81
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$4.07
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$3.46
|
| Rate for Payer: EmblemHealth Commercial |
$2.54
|
| Rate for Payer: Group Health Inc Commercial |
$2.54
|
| Rate for Payer: Group Health Inc Medicare |
$1.78
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.54
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2.54
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3.30
|
|
|
VENLAFAXINE HCL ER 150 MG PO CP24
|
Facility
|
OP
|
$4.57
|
|
|
Service Code
|
NDC 6808471311
|
| Hospital Charge Code |
6808471311
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.60 |
| Max. Negotiated Rate |
$3.66 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2.51
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.29
|
| Rate for Payer: Aetna Government |
$2.29
|
| Rate for Payer: Brighton Health Commercial |
$3.43
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$3.66
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$3.11
|
| Rate for Payer: EmblemHealth Commercial |
$2.29
|
| Rate for Payer: Group Health Inc Commercial |
$2.29
|
| Rate for Payer: Group Health Inc Medicare |
$1.60
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.29
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2.29
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2.97
|
|
|
VENLAFAXINE HCL ER 150 MG PO CP24
|
Facility
|
OP
|
$5.08
|
|
|
Service Code
|
NDC 0093738698
|
| Hospital Charge Code |
0093738698
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.78 |
| Max. Negotiated Rate |
$4.07 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2.80
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.54
|
| Rate for Payer: Aetna Government |
$2.54
|
| Rate for Payer: Brighton Health Commercial |
$3.81
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$4.07
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$3.46
|
| Rate for Payer: EmblemHealth Commercial |
$2.54
|
| Rate for Payer: Group Health Inc Commercial |
$2.54
|
| Rate for Payer: Group Health Inc Medicare |
$1.78
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.54
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2.54
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3.30
|
|
|
VENLAFAXINE HCL ER 150 MG PO CP24
|
Facility
|
IP
|
$5.08
|
|
|
Service Code
|
NDC 0093738698
|
| Hospital Charge Code |
0093738698
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.54 |
| Max. Negotiated Rate |
$2.54 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.54
|
|
|
VENLAFAXINE HCL ER 150 MG PO CP24
|
Facility
|
IP
|
$5.08
|
|
|
Service Code
|
NDC 6586269705
|
| Hospital Charge Code |
6586269705
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.54 |
| Max. Negotiated Rate |
$2.54 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.54
|
|
|
VENLAFAXINE HCL ER 150 MG PO CP24
|
Facility
|
IP
|
$4.57
|
|
|
Service Code
|
NDC 6808471301
|
| Hospital Charge Code |
6808471301
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.29 |
| Max. Negotiated Rate |
$2.29 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.29
|
|
|
VENLAFAXINE HCL ER 150 MG PO CP24
|
Facility
|
IP
|
$4.57
|
|
|
Service Code
|
NDC 6808471311
|
| Hospital Charge Code |
6808471311
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.29 |
| Max. Negotiated Rate |
$2.29 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.29
|
|
|
VENLAFAXINE HCL ER 37.5 MG PO CP24
|
Facility
|
IP
|
$4.16
|
|
|
Service Code
|
NDC 0093738498
|
| Hospital Charge Code |
0093738498
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.08 |
| Max. Negotiated Rate |
$2.08 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.08
|
|
|
VENLAFAXINE HCL ER 37.5 MG PO CP24
|
Facility
|
OP
|
$4.16
|
|
|
Service Code
|
NDC 6838203416
|
| Hospital Charge Code |
6838203416
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.46 |
| Max. Negotiated Rate |
$3.33 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2.29
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.08
|
| Rate for Payer: Aetna Government |
$2.08
|
| Rate for Payer: Brighton Health Commercial |
$3.12
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$3.33
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2.83
|
| Rate for Payer: EmblemHealth Commercial |
$2.08
|
| Rate for Payer: Group Health Inc Commercial |
$2.08
|
| Rate for Payer: Group Health Inc Medicare |
$1.46
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.08
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2.08
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2.71
|
|
|
VENLAFAXINE HCL ER 37.5 MG PO CP24
|
Facility
|
OP
|
$3.74
|
|
|
Service Code
|
NDC 6808469811
|
| Hospital Charge Code |
6808469811
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.31 |
| Max. Negotiated Rate |
$2.99 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2.06
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.87
|
| Rate for Payer: Aetna Government |
$1.87
|
| Rate for Payer: Brighton Health Commercial |
$2.81
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2.99
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2.54
|
| Rate for Payer: EmblemHealth Commercial |
$1.87
|
| Rate for Payer: Group Health Inc Commercial |
$1.87
|
| Rate for Payer: Group Health Inc Medicare |
$1.31
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.87
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.87
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2.43
|
|
|
VENLAFAXINE HCL ER 37.5 MG PO CP24
|
Facility
|
IP
|
$4.16
|
|
|
Service Code
|
NDC 6838203416
|
| Hospital Charge Code |
6838203416
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.08 |
| Max. Negotiated Rate |
$2.08 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.08
|
|
|
VENLAFAXINE HCL ER 37.5 MG PO CP24
|
Facility
|
OP
|
$4.16
|
|
|
Service Code
|
NDC 0093738498
|
| Hospital Charge Code |
0093738498
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.46 |
| Max. Negotiated Rate |
$3.33 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2.29
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.08
|
| Rate for Payer: Aetna Government |
$2.08
|
| Rate for Payer: Brighton Health Commercial |
$3.12
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$3.33
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2.83
|
| Rate for Payer: EmblemHealth Commercial |
$2.08
|
| Rate for Payer: Group Health Inc Commercial |
$2.08
|
| Rate for Payer: Group Health Inc Medicare |
$1.46
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.08
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2.08
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2.71
|
|
|
VENLAFAXINE HCL ER 37.5 MG PO CP24
|
Facility
|
IP
|
$3.74
|
|
|
Service Code
|
NDC 6808469811
|
| Hospital Charge Code |
6808469811
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.87 |
| Max. Negotiated Rate |
$1.87 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.87
|
|
|
VENLAFAXINE HCL ER 75 MG PO CP24
|
Facility
|
OP
|
$4.67
|
|
|
Service Code
|
NDC 0093738556
|
| Hospital Charge Code |
0093738556
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.63 |
| Max. Negotiated Rate |
$3.73 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2.57
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.33
|
| Rate for Payer: Aetna Government |
$2.33
|
| Rate for Payer: Brighton Health Commercial |
$3.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$3.73
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$3.17
|
| Rate for Payer: EmblemHealth Commercial |
$2.33
|
| Rate for Payer: Group Health Inc Commercial |
$2.33
|
| Rate for Payer: Group Health Inc Medicare |
$1.63
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.33
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2.33
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3.03
|
|
|
VENLAFAXINE HCL ER 75 MG PO CP24
|
Facility
|
OP
|
$4.67
|
|
|
Service Code
|
NDC 1366801990
|
| Hospital Charge Code |
1366801990
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.63 |
| Max. Negotiated Rate |
$3.74 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2.57
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.33
|
| Rate for Payer: Aetna Government |
$2.33
|
| Rate for Payer: Brighton Health Commercial |
$3.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$3.74
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$3.18
|
| Rate for Payer: EmblemHealth Commercial |
$2.33
|
| Rate for Payer: Group Health Inc Commercial |
$2.33
|
| Rate for Payer: Group Health Inc Medicare |
$1.63
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.33
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2.33
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3.04
|
|
|
VENLAFAXINE HCL ER 75 MG PO CP24
|
Facility
|
IP
|
$4.20
|
|
|
Service Code
|
NDC 6808470911
|
| Hospital Charge Code |
6808470911
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.10 |
| Max. Negotiated Rate |
$2.10 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.10
|
|
|
VENLAFAXINE HCL ER 75 MG PO CP24
|
Facility
|
IP
|
$4.67
|
|
|
Service Code
|
NDC 1366801990
|
| Hospital Charge Code |
1366801990
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.33 |
| Max. Negotiated Rate |
$2.33 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.33
|
|
|
VENLAFAXINE HCL ER 75 MG PO CP24
|
Facility
|
IP
|
$4.20
|
|
|
Service Code
|
NDC 6808470901
|
| Hospital Charge Code |
6808470901
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.10 |
| Max. Negotiated Rate |
$2.10 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.10
|
|
|
VENLAFAXINE HCL ER 75 MG PO CP24
|
Facility
|
IP
|
$4.67
|
|
|
Service Code
|
NDC 0093738598
|
| Hospital Charge Code |
0093738598
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.33 |
| Max. Negotiated Rate |
$2.33 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.33
|
|
|
VENLAFAXINE HCL ER 75 MG PO CP24
|
Facility
|
IP
|
$4.67
|
|
|
Service Code
|
NDC 6838203516
|
| Hospital Charge Code |
6838203516
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.33 |
| Max. Negotiated Rate |
$2.33 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.33
|
|
|
VENLAFAXINE HCL ER 75 MG PO CP24
|
Facility
|
OP
|
$4.20
|
|
|
Service Code
|
NDC 6808470901
|
| Hospital Charge Code |
6808470901
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.47 |
| Max. Negotiated Rate |
$3.36 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2.31
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.10
|
| Rate for Payer: Aetna Government |
$2.10
|
| Rate for Payer: Brighton Health Commercial |
$3.15
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$3.36
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2.85
|
| Rate for Payer: EmblemHealth Commercial |
$2.10
|
| Rate for Payer: Group Health Inc Commercial |
$2.10
|
| Rate for Payer: Group Health Inc Medicare |
$1.47
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.10
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2.10
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2.73
|
|
|
VENLAFAXINE HCL ER 75 MG PO CP24
|
Facility
|
OP
|
$4.67
|
|
|
Service Code
|
NDC 0093738598
|
| Hospital Charge Code |
0093738598
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.63 |
| Max. Negotiated Rate |
$3.73 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2.57
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.33
|
| Rate for Payer: Aetna Government |
$2.33
|
| Rate for Payer: Brighton Health Commercial |
$3.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$3.73
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$3.17
|
| Rate for Payer: EmblemHealth Commercial |
$2.33
|
| Rate for Payer: Group Health Inc Commercial |
$2.33
|
| Rate for Payer: Group Health Inc Medicare |
$1.63
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.33
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2.33
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3.03
|
|
