|
OMABOTULINUMTOXINA 200 U -PER 1U
|
Facility
|
OP
|
$10.39
|
|
|
Service Code
|
HCPCS J0585
|
| Hospital Charge Code |
41647907
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.43 |
| Max. Negotiated Rate |
$6.75 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$5.71
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$6.33
|
| Rate for Payer: Aetna Government |
$6.33
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$4.43
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$4.43
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$4.43
|
| Rate for Payer: Brighton Health Commercial |
$6.23
|
| Rate for Payer: Cash Price |
$6.33
|
| Rate for Payer: Cash Price |
$6.33
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$6.33
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$5.20
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$5.97
|
| Rate for Payer: Elderplan Medicare Advantage |
$6.33
|
| Rate for Payer: EmblemHealth Commercial |
$6.33
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$6.33
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$6.33
|
| Rate for Payer: Fidelis Essential Plan QHP |
$6.64
|
| Rate for Payer: Fidelis Medicare Advantage |
$6.33
|
| Rate for Payer: Fidelis Qualified Health Plan |
$6.64
|
| Rate for Payer: Group Health Inc Commercial |
$6.33
|
| Rate for Payer: Group Health Inc Medicare |
$6.33
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$5.20
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$5.20
|
| Rate for Payer: Healthfirst Medicare Advantage |
$5.38
|
| Rate for Payer: Healthfirst QHP |
$6.33
|
| Rate for Payer: Humana Medicare |
$6.45
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$6.33
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$6.70
|
| Rate for Payer: SOMOS Essential |
$6.70
|
| Rate for Payer: United Healthcare Commercial |
$6.32
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6.33
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$6.75
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$5.06
|
| Rate for Payer: Wellcare Medicare |
$6.01
|
|
|
OMABOTULINUMTOXINA 200 U -PER 1U
|
Facility
|
IP
|
$10.39
|
|
|
Service Code
|
HCPCS J0585
|
| Hospital Charge Code |
41647907
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.20 |
| Max. Negotiated Rate |
$5.20 |
| Rate for Payer: Cash Price |
$6.33
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$5.20
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$5.20
|
|
|
OMALIZUMAB 150MG INJ
|
Facility
|
IP
|
$29.46
|
|
|
Service Code
|
HCPCS J2357 JW
|
| Hospital Charge Code |
41659980
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.73 |
| Max. Negotiated Rate |
$14.73 |
| Rate for Payer: Cash Price |
$39.46
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$14.73
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$14.73
|
|
|
OMALIZUMAB 150MG INJ
|
Facility
|
IP
|
$29.46
|
|
|
Service Code
|
HCPCS J2357
|
| Hospital Charge Code |
41646580
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.73 |
| Max. Negotiated Rate |
$14.73 |
| Rate for Payer: Cash Price |
$39.46
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$14.73
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$14.73
|
|
|
OMALIZUMAB 150MG INJ
|
Facility
|
OP
|
$29.46
|
|
|
Service Code
|
HCPCS J2357
|
| Hospital Charge Code |
41646580
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.73 |
| Max. Negotiated Rate |
$41.43 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$16.20
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$39.46
|
| Rate for Payer: Aetna Government |
$39.46
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$27.62
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$27.62
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$27.62
|
| Rate for Payer: Brighton Health Commercial |
$17.68
|
| Rate for Payer: Cash Price |
$39.46
|
| Rate for Payer: Cash Price |
$39.46
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$39.46
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$14.73
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$16.94
|
| Rate for Payer: Elderplan Medicare Advantage |
$39.46
|
| Rate for Payer: EmblemHealth Commercial |
$39.46
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$39.46
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$39.46
|
| Rate for Payer: Fidelis Essential Plan QHP |
$41.43
|
| Rate for Payer: Fidelis Medicare Advantage |
$39.46
|
| Rate for Payer: Fidelis Qualified Health Plan |
$41.43
|
| Rate for Payer: Group Health Inc Commercial |
$39.46
|
| Rate for Payer: Group Health Inc Medicare |
$39.46
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$14.73
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$14.73
|
| Rate for Payer: Healthfirst Medicare Advantage |
$33.54
|
| Rate for Payer: Healthfirst QHP |
$39.46
|
| Rate for Payer: Humana Medicare |
$40.25
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$39.46
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$39.01
|
| Rate for Payer: SOMOS Essential |
$39.01
|
| Rate for Payer: United Healthcare Commercial |
$38.20
|
| Rate for Payer: United Healthcare Medicare Advantage |
$39.46
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$19.15
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$31.57
|
| Rate for Payer: Wellcare Medicare |
$37.49
|
|
|
OMALIZUMAB 150MG INJ
|
Facility
|
OP
|
$29.46
|
|
|
Service Code
|
HCPCS J2357
|
| Hospital Charge Code |
41656580
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.73 |
| Max. Negotiated Rate |
$41.43 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$16.20
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$39.46
|
| Rate for Payer: Aetna Government |
$39.46
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$27.62
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$27.62
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$27.62
|
| Rate for Payer: Brighton Health Commercial |
$17.68
|
| Rate for Payer: Cash Price |
$39.46
|
| Rate for Payer: Cash Price |
$39.46
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$39.46
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$14.73
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$16.94
|
| Rate for Payer: Elderplan Medicare Advantage |
$39.46
|
| Rate for Payer: EmblemHealth Commercial |
$39.46
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$39.46
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$39.46
|
| Rate for Payer: Fidelis Essential Plan QHP |
$41.43
|
| Rate for Payer: Fidelis Medicare Advantage |
$39.46
|
| Rate for Payer: Fidelis Qualified Health Plan |
$41.43
|
| Rate for Payer: Group Health Inc Commercial |
$39.46
|
| Rate for Payer: Group Health Inc Medicare |
$39.46
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$14.73
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$14.73
|
| Rate for Payer: Healthfirst Medicare Advantage |
$33.54
|
| Rate for Payer: Healthfirst QHP |
$39.46
|
| Rate for Payer: Humana Medicare |
$40.25
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$39.46
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$39.01
|
| Rate for Payer: SOMOS Essential |
$39.01
|
| Rate for Payer: United Healthcare Commercial |
$38.20
|
| Rate for Payer: United Healthcare Medicare Advantage |
$39.46
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$19.15
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$31.57
|
| Rate for Payer: Wellcare Medicare |
$37.49
|
|
|
OMALIZUMAB 150MG INJ
|
Facility
|
OP
|
$29.46
|
|
|
Service Code
|
HCPCS J2357 JW
|
| Hospital Charge Code |
41659980
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.73 |
| Max. Negotiated Rate |
$41.43 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$16.20
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$39.46
|
| Rate for Payer: Aetna Government |
$39.46
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$27.62
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$27.62
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$27.62
|
| Rate for Payer: Brighton Health Commercial |
$17.68
|
| Rate for Payer: Cash Price |
$39.46
|
| Rate for Payer: Cash Price |
$39.46
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$39.46
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$14.73
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$16.94
|
| Rate for Payer: Elderplan Medicare Advantage |
$39.46
|
| Rate for Payer: EmblemHealth Commercial |
$39.46
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$39.46
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$39.46
|
| Rate for Payer: Fidelis Essential Plan QHP |
$41.43
|
| Rate for Payer: Fidelis Medicare Advantage |
$39.46
|
| Rate for Payer: Fidelis Qualified Health Plan |
$41.43
|
| Rate for Payer: Group Health Inc Commercial |
$39.46
|
| Rate for Payer: Group Health Inc Medicare |
$39.46
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$14.73
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$14.73
|
| Rate for Payer: Healthfirst Medicare Advantage |
$33.54
|
| Rate for Payer: Healthfirst QHP |
$39.46
|
| Rate for Payer: Humana Medicare |
$40.25
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$39.46
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$39.01
|
| Rate for Payer: SOMOS Essential |
$39.01
|
| Rate for Payer: United Healthcare Commercial |
$38.20
|
| Rate for Payer: United Healthcare Medicare Advantage |
$39.46
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$19.15
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$31.57
|
| Rate for Payer: Wellcare Medicare |
$37.49
|
|
|
OMALIZUMAB 150MG INJ
|
Facility
|
IP
|
$29.46
|
|
|
Service Code
|
HCPCS J2357
|
| Hospital Charge Code |
41656580
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.73 |
| Max. Negotiated Rate |
$14.73 |
| Rate for Payer: Cash Price |
$39.46
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$14.73
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$14.73
|
|
|
OMALIZUMAB 150 MG/ML SC SOAJ [194218]
|
Facility
|
OP
|
$1,661.95
|
|
|
Service Code
|
NDC 50242021555
|
| Hospital Charge Code |
50242021555
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$581.68 |
| Max. Negotiated Rate |
$1,329.56 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$914.07
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$830.98
|
| Rate for Payer: Aetna Government |
$830.98
|
| Rate for Payer: Brighton Health Commercial |
$1,246.46
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,329.56
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,130.13
|
| Rate for Payer: Group Health Inc Commercial |
$830.98
|
| Rate for Payer: Group Health Inc Medicare |
$581.68
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$830.98
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$830.98
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,080.27
|
|
|
OMALIZUMAB 150 MG SC SOLR [36151]
|
Facility
|
OP
|
$1,661.95
|
|
|
Service Code
|
HCPCS J2357
|
| Hospital Charge Code |
50242004062
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$27.62 |
| Max. Negotiated Rate |
$1,329.56 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$914.07
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$39.46
|
| Rate for Payer: Aetna Government |
$39.46
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$27.62
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$27.62
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$27.62
|
| Rate for Payer: Brighton Health Commercial |
$1,246.46
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$39.46
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,329.56
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,130.13
|
| Rate for Payer: Elderplan Medicare Advantage |
$39.46
|
| Rate for Payer: EmblemHealth Commercial |
$39.46
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$33.54
|
| Rate for Payer: Fidelis Essential Plan QHP |
$35.12
|
| Rate for Payer: Fidelis Medicare Advantage |
$39.46
|
| Rate for Payer: Fidelis Qualified Health Plan |
$35.12
|
| Rate for Payer: Group Health Inc Commercial |
$39.46
|
| Rate for Payer: Group Health Inc Medicare |
$39.46
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$830.98
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$39.46
|
| Rate for Payer: Healthfirst Medicare Advantage |
$33.54
|
| Rate for Payer: Healthfirst QHP |
$39.46
|
| Rate for Payer: Humana Medicare |
$40.25
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$36.81
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$39.01
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$39.01
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$39.01
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$39.46
|
| Rate for Payer: United Healthcare Medicare Advantage |
$39.46
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,080.27
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$31.57
|
| Rate for Payer: Wellcare Medicare |
$37.49
|
|
|
OMALIZUMAB 300 MG/2ML SC SOAJ [194219]
|
Facility
|
OP
|
$1,661.95
|
|
|
Service Code
|
NDC 50242022755
|
| Hospital Charge Code |
50242022755
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$581.68 |
| Max. Negotiated Rate |
$1,329.56 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$914.07
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$830.98
|
| Rate for Payer: Aetna Government |
$830.98
|
| Rate for Payer: Brighton Health Commercial |
$1,246.46
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,329.56
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,130.13
|
| Rate for Payer: Group Health Inc Commercial |
$830.98
|
| Rate for Payer: Group Health Inc Medicare |
$581.68
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$830.98
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$830.98
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,080.27
|
|
|
OMALIZUMAB 300 MG/2 ML SC SOSY [194216]
|
Facility
|
OP
|
$1,661.95
|
|
|
Service Code
|
HCPCS J2357
|
| Hospital Charge Code |
50242022701
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$27.62 |
| Max. Negotiated Rate |
$1,329.56 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$914.07
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$39.46
|
| Rate for Payer: Aetna Government |
$39.46
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$27.62
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$27.62
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$27.62
|
| Rate for Payer: Brighton Health Commercial |
$1,246.46
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$39.46
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,329.56
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,130.13
|
| Rate for Payer: Elderplan Medicare Advantage |
$39.46
|
| Rate for Payer: EmblemHealth Commercial |
$39.46
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$33.54
|
| Rate for Payer: Fidelis Essential Plan QHP |
$35.12
|
| Rate for Payer: Fidelis Medicare Advantage |
$39.46
|
| Rate for Payer: Fidelis Qualified Health Plan |
$35.12
|
| Rate for Payer: Group Health Inc Commercial |
$39.46
|
| Rate for Payer: Group Health Inc Medicare |
$39.46
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$830.98
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$39.46
|
| Rate for Payer: Healthfirst Medicare Advantage |
$33.54
|
| Rate for Payer: Healthfirst QHP |
$39.46
|
| Rate for Payer: Humana Medicare |
$40.25
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$36.81
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$39.01
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$39.01
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$39.01
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$39.46
|
| Rate for Payer: United Healthcare Medicare Advantage |
$39.46
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,080.27
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$31.57
|
| Rate for Payer: Wellcare Medicare |
$37.49
|
|
|
OMALIZUMAB 75MG/0.5ML PFS INJ
|
Facility
|
IP
|
$90.40
|
|
|
Service Code
|
HCPCS J2357
|
| Hospital Charge Code |
41653894
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$45.20 |
| Max. Negotiated Rate |
$45.20 |
| Rate for Payer: Cash Price |
$39.46
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$45.20
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$45.20
|
|
|
OMALIZUMAB 75MG/0.5ML PFS INJ
|
Facility
|
OP
|
$90.40
|
|
|
Service Code
|
HCPCS J2357
|
| Hospital Charge Code |
41643894
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$27.62 |
| Max. Negotiated Rate |
$58.76 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$49.72
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$39.46
|
| Rate for Payer: Aetna Government |
$39.46
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$27.62
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$27.62
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$27.62
|
| Rate for Payer: Brighton Health Commercial |
$54.24
|
| Rate for Payer: Cash Price |
$39.46
|
| Rate for Payer: Cash Price |
$39.46
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$39.46
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$45.20
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$51.98
|
| Rate for Payer: Elderplan Medicare Advantage |
$39.46
|
| Rate for Payer: EmblemHealth Commercial |
$39.46
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$39.46
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$39.46
|
| Rate for Payer: Fidelis Essential Plan QHP |
$41.43
|
| Rate for Payer: Fidelis Medicare Advantage |
$39.46
|
| Rate for Payer: Fidelis Qualified Health Plan |
$41.43
|
| Rate for Payer: Group Health Inc Commercial |
$39.46
|
| Rate for Payer: Group Health Inc Medicare |
$39.46
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$45.20
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$45.20
|
| Rate for Payer: Healthfirst Medicare Advantage |
$33.54
|
| Rate for Payer: Healthfirst QHP |
$39.46
|
| Rate for Payer: Humana Medicare |
$40.25
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$39.46
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$39.01
|
| Rate for Payer: SOMOS Essential |
$39.01
|
| Rate for Payer: United Healthcare Commercial |
$38.20
|
| Rate for Payer: United Healthcare Medicare Advantage |
$39.46
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$58.76
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$31.57
|
| Rate for Payer: Wellcare Medicare |
$37.49
|
|
|
OMALIZUMAB 75MG/0.5ML PFS INJ
|
Facility
|
IP
|
$90.40
|
|
|
Service Code
|
HCPCS J2357
|
| Hospital Charge Code |
41643894
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$45.20 |
| Max. Negotiated Rate |
$45.20 |
| Rate for Payer: Cash Price |
$39.46
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$45.20
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$45.20
|
|
|
OMALIZUMAB 75MG/0.5ML PFS INJ
|
Facility
|
OP
|
$90.40
|
|
|
Service Code
|
HCPCS J2357
|
| Hospital Charge Code |
41653894
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$27.62 |
| Max. Negotiated Rate |
$58.76 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$49.72
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$39.46
|
| Rate for Payer: Aetna Government |
$39.46
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$27.62
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$27.62
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$27.62
|
| Rate for Payer: Brighton Health Commercial |
$54.24
|
| Rate for Payer: Cash Price |
$39.46
|
| Rate for Payer: Cash Price |
$39.46
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$39.46
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$45.20
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$51.98
|
| Rate for Payer: Elderplan Medicare Advantage |
$39.46
|
| Rate for Payer: EmblemHealth Commercial |
$39.46
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$39.46
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$39.46
|
| Rate for Payer: Fidelis Essential Plan QHP |
$41.43
|
| Rate for Payer: Fidelis Medicare Advantage |
$39.46
|
| Rate for Payer: Fidelis Qualified Health Plan |
$41.43
|
| Rate for Payer: Group Health Inc Commercial |
$39.46
|
| Rate for Payer: Group Health Inc Medicare |
$39.46
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$45.20
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$45.20
|
| Rate for Payer: Healthfirst Medicare Advantage |
$33.54
|
| Rate for Payer: Healthfirst QHP |
$39.46
|
| Rate for Payer: Humana Medicare |
$40.25
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$39.46
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$39.01
|
| Rate for Payer: SOMOS Essential |
$39.01
|
| Rate for Payer: United Healthcare Commercial |
$38.20
|
| Rate for Payer: United Healthcare Medicare Advantage |
$39.46
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$58.76
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$31.57
|
| Rate for Payer: Wellcare Medicare |
$37.49
|
|
|
OMALIZUMAB 75 MG/0.5ML SC SOAJ [194217]
|
Facility
|
OP
|
$1,661.96
|
|
|
Service Code
|
NDC 50242021455
|
| Hospital Charge Code |
50242021455
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$581.69 |
| Max. Negotiated Rate |
$1,329.57 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$914.08
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$830.98
|
| Rate for Payer: Aetna Government |
$830.98
|
| Rate for Payer: Brighton Health Commercial |
$1,246.47
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,329.57
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,130.13
|
| Rate for Payer: Group Health Inc Commercial |
$830.98
|
| Rate for Payer: Group Health Inc Medicare |
$581.69
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$830.98
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$830.98
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,080.27
|
|
|
OMALIZUMAB 75 MG/0.5ML SC SOSY [164489]
|
Facility
|
OP
|
$1,661.96
|
|
|
Service Code
|
HCPCS J2357
|
| Hospital Charge Code |
50242021401
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$27.62 |
| Max. Negotiated Rate |
$1,329.57 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$914.08
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$39.46
|
| Rate for Payer: Aetna Government |
$39.46
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$27.62
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$27.62
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$27.62
|
| Rate for Payer: Brighton Health Commercial |
$1,246.47
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$39.46
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,329.57
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,130.13
|
| Rate for Payer: Elderplan Medicare Advantage |
$39.46
|
| Rate for Payer: EmblemHealth Commercial |
$39.46
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$33.54
|
| Rate for Payer: Fidelis Essential Plan QHP |
$35.12
|
| Rate for Payer: Fidelis Medicare Advantage |
$39.46
|
| Rate for Payer: Fidelis Qualified Health Plan |
$35.12
|
| Rate for Payer: Group Health Inc Commercial |
$39.46
|
| Rate for Payer: Group Health Inc Medicare |
$39.46
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$830.98
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$39.46
|
| Rate for Payer: Healthfirst Medicare Advantage |
$33.54
|
| Rate for Payer: Healthfirst QHP |
$39.46
|
| Rate for Payer: Humana Medicare |
$40.25
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$36.81
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$39.01
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$39.01
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$39.01
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$39.46
|
| Rate for Payer: United Healthcare Medicare Advantage |
$39.46
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,080.27
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$31.57
|
| Rate for Payer: Wellcare Medicare |
$37.49
|
|
|
OMENTECTOMY
|
Facility
|
OP
|
$2,365.81
|
|
|
Service Code
|
HCPCS 49255
|
| Hospital Charge Code |
40011195
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$828.03 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,301.20
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$933.33
|
| Rate for Payer: Aetna Government |
$933.33
|
| Rate for Payer: Brighton Health Commercial |
$1,774.36
|
| 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: EmblemHealth Commercial |
$1,505.00
|
| Rate for Payer: Group Health Inc Commercial |
$1,182.90
|
| Rate for Payer: Group Health Inc Medicare |
$828.03
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,182.90
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,182.90
|
| Rate for Payer: United Healthcare Commercial |
$1,468.00
|
|
|
OMNIFIT UNIV DISTAL CEMENT SPACER
|
Facility
|
OP
|
$262.40
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
40201383
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$91.84 |
| Max. Negotiated Rate |
$275.52 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$144.32
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$134.20
|
| Rate for Payer: Aetna Government |
$134.20
|
| Rate for Payer: Brighton Health Commercial |
$157.44
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$131.20
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$150.88
|
| Rate for Payer: EmblemHealth Commercial |
$131.20
|
| Rate for Payer: Fidelis Medicare Advantage |
$275.52
|
| Rate for Payer: Group Health Inc Commercial |
$131.20
|
| Rate for Payer: Group Health Inc Medicare |
$91.84
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$131.20
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$131.20
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$170.56
|
|
|
OMNIFIT UNIV DISTAL CEMENT SPACER
|
Facility
|
IP
|
$262.40
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
40201383
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$131.20 |
| Max. Negotiated Rate |
$131.20 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$131.20
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$131.20
|
|
|
OMNI HOOK
|
Facility
|
OP
|
$19.65
|
|
| Hospital Charge Code |
64902747
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$6.88 |
| Max. Negotiated Rate |
$15.72 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$10.81
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$9.82
|
| Rate for Payer: Aetna Government |
$9.82
|
| Rate for Payer: Brighton Health Commercial |
$14.74
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$15.72
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$13.36
|
| Rate for Payer: Group Health Inc Commercial |
$9.82
|
| Rate for Payer: Group Health Inc Medicare |
$6.88
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$9.82
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$9.82
|
|
|
OMNIPAQUE 240 50ML ORAL - 1ML
|
Facility
|
OP
|
$0.10
|
|
|
Service Code
|
HCPCS Q9966
|
| Hospital Charge Code |
41648425
|
|
Hospital Revenue Code
|
254
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.41 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.06
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.34
|
| Rate for Payer: Aetna Government |
$0.34
|
| Rate for Payer: Brighton Health Commercial |
$0.08
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.08
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.07
|
| Rate for Payer: Group Health Inc Commercial |
$0.05
|
| Rate for Payer: Group Health Inc Medicare |
$0.04
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.05
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.05
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$0.39
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$0.41
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$0.41
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$0.41
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.07
|
|
|
OMNIPAQUE 300MG/ML - 100ML 1ML
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
41648018
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.65 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.55
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.12
|
| Rate for Payer: Aetna Government |
$0.12
|
| Rate for Payer: Brighton Health Commercial |
$0.60
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.50
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.58
|
| Rate for Payer: Group Health Inc Commercial |
$0.50
|
| Rate for Payer: Group Health Inc Medicare |
$0.35
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.50
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$0.15
|
| Rate for Payer: SOMOS Essential |
$0.15
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.65
|
|
|
OMNIPAQUE 300MG/ML - 100ML 1ML
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
41648018
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$0.50 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.50
|
|
