St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

COAGULATION FACTOR X (HUMAN) 250 UNITS IV SOLR

Facility

$13.66

Service Code	HCPCS J7175
Hospital Charge Code	6420877521
Hospital Revenue Code	258
Min. Negotiated Rate	$6.85
Max. Negotiated Rate	$10.93
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$7.51
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$9.78
Rate for Payer: Aetna Government	$9.78
Rate for Payer: Affinity Essential Plan 1&2	$6.85
Rate for Payer: Affinity Essential Plan 3&4	$6.85
Rate for Payer: Affinity Medicaid/CHP/HARP	$6.85
Rate for Payer: Brighton Health Commercial	$10.24
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$9.78
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$10.93
Rate for Payer: Cigna LocalPlus Benefit Plan	$9.29
Rate for Payer: Elderplan Medicare Advantage	$9.78
Rate for Payer: EmblemHealth Commercial	$9.78
Rate for Payer: Fidelis CHP/HARP/Medicaid	$8.80
Rate for Payer: Fidelis Essential Plan Aliesa	$8.31
Rate for Payer: Fidelis Essential Plan QHP	$8.70
Rate for Payer: Fidelis Medicare Advantage	$9.78
Rate for Payer: Fidelis Qualified Health Plan	$8.70
Rate for Payer: Group Health Inc Commercial	$9.78
Rate for Payer: Group Health Inc Medicare	$9.78
Rate for Payer: Hamaspik Choice Inc Medicaid	$9.78
Rate for Payer: Hamaspik Choice Inc Medicare	$9.78
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$9.78
Rate for Payer: Healthfirst Medicare Advantage	$8.31
Rate for Payer: Healthfirst QHP	$9.78
Rate for Payer: Humana Medicare	$9.98
Rate for Payer: Senior Whole Health Medicare Advantage	$9.78
Rate for Payer: United Healthcare Medicare Advantage	$9.78
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$8.88
Rate for Payer: Wellcare CHP/FHP/Medicaid	$9.29
Rate for Payer: Wellcare Medicare	$9.29

COAGULATION FACTOR X (HUMAN) 250 UNITS IV SOLR

Facility

$13.66

Service Code	HCPCS J7175
Hospital Charge Code	6420877521
Hospital Revenue Code	258
Min. Negotiated Rate	$6.83
Max. Negotiated Rate	$6.83
Rate for Payer: Hamaspik Choice Inc Medicaid	$6.83

COAGULATION FACTOR X (HUMAN) 250 UNITS IV SOLR

Facility

$13.66

Service Code	HCPCS J7175
Hospital Charge Code	6420877541
Hospital Revenue Code	258
Min. Negotiated Rate	$6.83
Max. Negotiated Rate	$6.83
Rate for Payer: Hamaspik Choice Inc Medicaid	$6.83

COAGULATION FACTOR X (HUMAN) 250 UNITS IV SOLR

Facility

$13.66

Service Code	HCPCS J7175
Hospital Charge Code	6420877541
Hospital Revenue Code	258
Min. Negotiated Rate	$6.85
Max. Negotiated Rate	$10.93
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$7.51
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$9.78
Rate for Payer: Aetna Government	$9.78
Rate for Payer: Affinity Essential Plan 1&2	$6.85
Rate for Payer: Affinity Essential Plan 3&4	$6.85
Rate for Payer: Affinity Medicaid/CHP/HARP	$6.85
Rate for Payer: Brighton Health Commercial	$10.24
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$9.78
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$10.93
Rate for Payer: Cigna LocalPlus Benefit Plan	$9.29
Rate for Payer: Elderplan Medicare Advantage	$9.78
Rate for Payer: EmblemHealth Commercial	$9.78
Rate for Payer: Fidelis CHP/HARP/Medicaid	$8.80
Rate for Payer: Fidelis Essential Plan Aliesa	$8.31
Rate for Payer: Fidelis Essential Plan QHP	$8.70
Rate for Payer: Fidelis Medicare Advantage	$9.78
Rate for Payer: Fidelis Qualified Health Plan	$8.70
Rate for Payer: Group Health Inc Commercial	$9.78
Rate for Payer: Group Health Inc Medicare	$9.78
Rate for Payer: Hamaspik Choice Inc Medicaid	$9.78
Rate for Payer: Hamaspik Choice Inc Medicare	$9.78
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$9.78
Rate for Payer: Healthfirst Medicare Advantage	$8.31
Rate for Payer: Healthfirst QHP	$9.78
Rate for Payer: Humana Medicare	$9.98
Rate for Payer: Senior Whole Health Medicare Advantage	$9.78
Rate for Payer: United Healthcare Medicare Advantage	$9.78
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$8.88
Rate for Payer: Wellcare CHP/FHP/Medicaid	$9.29
Rate for Payer: Wellcare Medicare	$9.29

COAGULATION FACTOR X (HUMAN) 500 UNITS IV SOLR

Facility

$13.66

Service Code	HCPCS J7175
Hospital Charge Code	6420877531
Hospital Revenue Code	258
Min. Negotiated Rate	$6.83
Max. Negotiated Rate	$6.83
Rate for Payer: Hamaspik Choice Inc Medicaid	$6.83

COAGULATION FACTOR X (HUMAN) 500 UNITS IV SOLR

Facility

$13.66

Service Code	HCPCS J7175
Hospital Charge Code	6420877561
Hospital Revenue Code	258
Min. Negotiated Rate	$6.83
Max. Negotiated Rate	$6.83
Rate for Payer: Hamaspik Choice Inc Medicaid	$6.83

COAGULATION FACTOR X (HUMAN) 500 UNITS IV SOLR

Facility

$13.66

Service Code	HCPCS J7175
Hospital Charge Code	6420877531
Hospital Revenue Code	258
Min. Negotiated Rate	$6.85
Max. Negotiated Rate	$10.93
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$7.51
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$9.78
Rate for Payer: Aetna Government	$9.78
Rate for Payer: Affinity Essential Plan 1&2	$6.85
Rate for Payer: Affinity Essential Plan 3&4	$6.85
Rate for Payer: Affinity Medicaid/CHP/HARP	$6.85
Rate for Payer: Brighton Health Commercial	$10.24
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$9.78
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$10.93
Rate for Payer: Cigna LocalPlus Benefit Plan	$9.29
Rate for Payer: Elderplan Medicare Advantage	$9.78
Rate for Payer: EmblemHealth Commercial	$9.78
Rate for Payer: Fidelis CHP/HARP/Medicaid	$8.80
Rate for Payer: Fidelis Essential Plan Aliesa	$8.31
Rate for Payer: Fidelis Essential Plan QHP	$8.70
Rate for Payer: Fidelis Medicare Advantage	$9.78
Rate for Payer: Fidelis Qualified Health Plan	$8.70
Rate for Payer: Group Health Inc Commercial	$9.78
Rate for Payer: Group Health Inc Medicare	$9.78
Rate for Payer: Hamaspik Choice Inc Medicaid	$9.78
Rate for Payer: Hamaspik Choice Inc Medicare	$9.78
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$9.78
Rate for Payer: Healthfirst Medicare Advantage	$8.31
Rate for Payer: Healthfirst QHP	$9.78
Rate for Payer: Humana Medicare	$9.98
Rate for Payer: Senior Whole Health Medicare Advantage	$9.78
Rate for Payer: United Healthcare Medicare Advantage	$9.78
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$8.88
Rate for Payer: Wellcare CHP/FHP/Medicaid	$9.29
Rate for Payer: Wellcare Medicare	$9.29

COAGULATION FACTOR X (HUMAN) 500 UNITS IV SOLR

Facility

$13.66

Service Code	HCPCS J7175
Hospital Charge Code	6420877561
Hospital Revenue Code	258
Min. Negotiated Rate	$6.85
Max. Negotiated Rate	$10.93
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$7.51
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$9.78
Rate for Payer: Aetna Government	$9.78
Rate for Payer: Affinity Essential Plan 1&2	$6.85
Rate for Payer: Affinity Essential Plan 3&4	$6.85
Rate for Payer: Affinity Medicaid/CHP/HARP	$6.85
Rate for Payer: Brighton Health Commercial	$10.24
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$9.78
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$10.93
Rate for Payer: Cigna LocalPlus Benefit Plan	$9.29
Rate for Payer: Elderplan Medicare Advantage	$9.78
Rate for Payer: EmblemHealth Commercial	$9.78
Rate for Payer: Fidelis CHP/HARP/Medicaid	$8.80
Rate for Payer: Fidelis Essential Plan Aliesa	$8.31
Rate for Payer: Fidelis Essential Plan QHP	$8.70
Rate for Payer: Fidelis Medicare Advantage	$9.78
Rate for Payer: Fidelis Qualified Health Plan	$8.70
Rate for Payer: Group Health Inc Commercial	$9.78
Rate for Payer: Group Health Inc Medicare	$9.78
Rate for Payer: Hamaspik Choice Inc Medicaid	$9.78
Rate for Payer: Hamaspik Choice Inc Medicare	$9.78
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$9.78
Rate for Payer: Healthfirst Medicare Advantage	$8.31
Rate for Payer: Healthfirst QHP	$9.78
Rate for Payer: Humana Medicare	$9.98
Rate for Payer: Senior Whole Health Medicare Advantage	$9.78
Rate for Payer: United Healthcare Medicare Advantage	$9.78
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$8.88
Rate for Payer: Wellcare CHP/FHP/Medicaid	$9.29
Rate for Payer: Wellcare Medicare	$9.29

Coagulation & platelet disorders

Facility

$66,414.22

Service Code	APR-DRG 6613
Min. Negotiated Rate	$17,990.00
Max. Negotiated Rate	$66,414.22
Rate for Payer: Affinity Essential Plan 1&2	$66,414.22
Rate for Payer: Affinity Essential Plan 3&4	$66,414.22
Rate for Payer: Affinity Medicaid/CHP/HARP	$29,517.43
Rate for Payer: Amida Care Medicaid	$29,517.43
Rate for Payer: EmblemHealth Essential Plan 1&2	$66,414.22
Rate for Payer: EmblemHealth Essential Plan 3&4	$29,517.43
Rate for Payer: Fidelis CHP/HARP/Medicaid	$29,517.43
Rate for Payer: Fidelis Qualified Health Plan	$35,420.92
Rate for Payer: Hamaspik Choice Inc Medicaid	$29,517.43
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$29,517.43
Rate for Payer: Healthfirst Commercial	$31,215.00
Rate for Payer: Healthfirst Essential Plan	$66,414.22
Rate for Payer: Healthfirst QHP	$17,990.00
Rate for Payer: SOMOS CHP/HARP/Medicaid	$29,517.43
Rate for Payer: SOMOS Essential	$66,414.22
Rate for Payer: United Healthcare Essential Plan 1&2	$66,414.22
Rate for Payer: United Healthcare Essential Plan 3&4	$66,414.22
Rate for Payer: United Healthcare Medicaid	$29,517.43
Rate for Payer: Wellcare CHP/FHP/Medicaid	$29,517.43

Coagulation & platelet disorders

Facility

$49,772.97

Service Code	APR-DRG 6611
Min. Negotiated Rate	$8,953.00
Max. Negotiated Rate	$49,772.97
Rate for Payer: Affinity Essential Plan 1&2	$49,772.97
Rate for Payer: Affinity Essential Plan 3&4	$49,772.97
Rate for Payer: Affinity Medicaid/CHP/HARP	$22,121.32
Rate for Payer: Amida Care Medicaid	$22,121.32
Rate for Payer: EmblemHealth Essential Plan 1&2	$49,772.97
Rate for Payer: EmblemHealth Essential Plan 3&4	$22,121.32
Rate for Payer: Fidelis CHP/HARP/Medicaid	$22,121.32
Rate for Payer: Fidelis Qualified Health Plan	$26,545.58
Rate for Payer: Hamaspik Choice Inc Medicaid	$22,121.32
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$22,121.32
Rate for Payer: Healthfirst Commercial	$15,482.00
Rate for Payer: Healthfirst Essential Plan	$49,772.97
Rate for Payer: Healthfirst QHP	$8,953.00
Rate for Payer: SOMOS CHP/HARP/Medicaid	$22,121.32
Rate for Payer: SOMOS Essential	$49,772.97
Rate for Payer: United Healthcare Essential Plan 1&2	$49,772.97
Rate for Payer: United Healthcare Essential Plan 3&4	$49,772.97
Rate for Payer: United Healthcare Medicaid	$22,121.32
Rate for Payer: Wellcare CHP/FHP/Medicaid	$22,121.32

Coagulation & platelet disorders

Facility

$52,871.87

Service Code	APR-DRG 6612
Min. Negotiated Rate	$11,275.00
Max. Negotiated Rate	$52,871.87
Rate for Payer: Affinity Essential Plan 1&2	$52,871.87
Rate for Payer: Affinity Essential Plan 3&4	$52,871.87
Rate for Payer: Affinity Medicaid/CHP/HARP	$23,498.61
Rate for Payer: Amida Care Medicaid	$23,498.61
Rate for Payer: EmblemHealth Essential Plan 1&2	$52,871.87
Rate for Payer: EmblemHealth Essential Plan 3&4	$23,498.61
Rate for Payer: Fidelis CHP/HARP/Medicaid	$23,498.61
Rate for Payer: Fidelis Qualified Health Plan	$28,198.33
Rate for Payer: Hamaspik Choice Inc Medicaid	$23,498.61
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$23,498.61
Rate for Payer: Healthfirst Commercial	$19,661.00
Rate for Payer: Healthfirst Essential Plan	$52,871.87
Rate for Payer: Healthfirst QHP	$11,275.00
Rate for Payer: SOMOS CHP/HARP/Medicaid	$23,498.61
Rate for Payer: SOMOS Essential	$52,871.87
Rate for Payer: United Healthcare Essential Plan 1&2	$52,871.87
Rate for Payer: United Healthcare Essential Plan 3&4	$52,871.87
Rate for Payer: United Healthcare Medicaid	$23,498.61
Rate for Payer: Wellcare CHP/FHP/Medicaid	$23,498.61

Coagulation & platelet disorders

Facility

$112,322.79

Service Code	APR-DRG 6614
Min. Negotiated Rate	$38,418.00
Max. Negotiated Rate	$112,322.79
Rate for Payer: Affinity Essential Plan 1&2	$112,322.79
Rate for Payer: Affinity Essential Plan 3&4	$112,322.79
Rate for Payer: Affinity Medicaid/CHP/HARP	$49,921.24
Rate for Payer: Amida Care Medicaid	$49,921.24
Rate for Payer: EmblemHealth Essential Plan 1&2	$112,322.79
Rate for Payer: EmblemHealth Essential Plan 3&4	$49,921.24
Rate for Payer: Fidelis CHP/HARP/Medicaid	$49,921.24
Rate for Payer: Fidelis Qualified Health Plan	$59,905.49
Rate for Payer: Hamaspik Choice Inc Medicaid	$49,921.24
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$49,921.24
Rate for Payer: Healthfirst Commercial	$86,445.00
Rate for Payer: Healthfirst Essential Plan	$112,322.79
Rate for Payer: Healthfirst QHP	$38,418.00
Rate for Payer: SOMOS CHP/HARP/Medicaid	$49,921.24
Rate for Payer: SOMOS Essential	$112,322.79
Rate for Payer: United Healthcare Essential Plan 1&2	$112,322.79
Rate for Payer: United Healthcare Essential Plan 3&4	$112,322.79
Rate for Payer: United Healthcare Medicaid	$49,921.24
Rate for Payer: Wellcare CHP/FHP/Medicaid	$49,921.24

COAL TAR EXTRACT 1 % EX SHAM

Facility

$0.06

Service Code	NDC 0187141616
Hospital Charge Code	0187141616
Hospital Revenue Code	250
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.04
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.03
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.03
Rate for Payer: Aetna Government	$0.03
Rate for Payer: Brighton Health Commercial	$0.04
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.04
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.04
Rate for Payer: EmblemHealth Commercial	$0.03
Rate for Payer: Group Health Inc Commercial	$0.03
Rate for Payer: Group Health Inc Medicare	$0.02
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.03
Rate for Payer: Hamaspik Choice Inc Medicare	$0.03
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.04

COAL TAR EXTRACT 1 % EX SHAM

Facility

$0.04

Service Code	NDC 50428030837
Hospital Charge Code	50428030837
Hospital Revenue Code	250
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.03
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.02
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.02
Rate for Payer: Aetna Government	$0.02
Rate for Payer: Brighton Health Commercial	$0.03
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.03
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.02
Rate for Payer: EmblemHealth Commercial	$0.02
Rate for Payer: Group Health Inc Commercial	$0.02
Rate for Payer: Group Health Inc Medicare	$0.01
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.02
Rate for Payer: Hamaspik Choice Inc Medicare	$0.02
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.02

COAL TAR EXTRACT 1 % EX SHAM

Facility

$0.04

Service Code	NDC 50428030837
Hospital Charge Code	50428030837
Hospital Revenue Code	250
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.02
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.02

COAL TAR EXTRACT 1 % EX SHAM

Facility

$0.06

Service Code	NDC 0187141616
Hospital Charge Code	0187141616
Hospital Revenue Code	250
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.03
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.03

COCAINE ABUSE AND DEPENDENCE

Facility

$254.31

Service Code	EAPG 00841
Min. Negotiated Rate	$185.14
Max. Negotiated Rate	$254.31
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$185.14
Rate for Payer: Healthfirst Commercial	$254.31

Cocaine abuse & dependence

Facility

$10,811.00

Service Code	APR-DRG 7741
Min. Negotiated Rate	$3,319.34
Max. Negotiated Rate	$10,811.00
Rate for Payer: Affinity Essential Plan 1&2	$3,319.34
Rate for Payer: Affinity Essential Plan 3&4	$3,319.34
Rate for Payer: Affinity Medicaid/CHP/HARP	$3,319.34
Rate for Payer: Carelon Behavioral Health HARP/QHP	$3,319.34
Rate for Payer: EmblemHealth Essential Plan 1&2	$7,468.52
Rate for Payer: EmblemHealth Essential Plan 3&4	$3,319.34
Rate for Payer: Fidelis Qualified Health Plan	$3,983.21
Rate for Payer: Hamaspik Choice Inc Medicaid	$3,319.34
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$3,319.34
Rate for Payer: Healthfirst Commercial	$10,811.00
Rate for Payer: Healthfirst Essential Plan	$7,468.52
Rate for Payer: Healthfirst QHP	$6,041.20
Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid	$3,319.34
Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa)	$7,468.52
Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa)	$7,468.52
Rate for Payer: SOMOS CHP/HARP/Medicaid	$3,319.34
Rate for Payer: SOMOS Essential	$7,468.52
Rate for Payer: United Healthcare Essential Plan 1&2	$7,468.52
Rate for Payer: United Healthcare Essential Plan 3&4	$7,468.52
Rate for Payer: United Healthcare Medicaid	$3,319.34

Cocaine abuse & dependence

Facility

$13,346.00

Service Code	APR-DRG 7743
Min. Negotiated Rate	$3,395.58
Max. Negotiated Rate	$13,346.00
Rate for Payer: Affinity Essential Plan 1&2	$3,395.58
Rate for Payer: Affinity Essential Plan 3&4	$3,395.58
Rate for Payer: Affinity Medicaid/CHP/HARP	$3,395.58
Rate for Payer: Carelon Behavioral Health HARP/QHP	$3,395.58
Rate for Payer: EmblemHealth Essential Plan 1&2	$7,640.06
Rate for Payer: EmblemHealth Essential Plan 3&4	$3,395.58
Rate for Payer: Fidelis Qualified Health Plan	$4,074.70
Rate for Payer: Hamaspik Choice Inc Medicaid	$3,395.58
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$3,395.58
Rate for Payer: Healthfirst Commercial	$13,346.00
Rate for Payer: Healthfirst Essential Plan	$7,640.06
Rate for Payer: Healthfirst QHP	$6,179.96
Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid	$3,395.58
Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa)	$7,640.06
Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa)	$7,640.06
Rate for Payer: SOMOS CHP/HARP/Medicaid	$3,395.58
Rate for Payer: SOMOS Essential	$7,640.06
Rate for Payer: United Healthcare Essential Plan 1&2	$7,640.06
Rate for Payer: United Healthcare Essential Plan 3&4	$7,640.06
Rate for Payer: United Healthcare Medicaid	$3,395.58

Cocaine abuse & dependence

Facility

$16,488.00

Service Code	APR-DRG 7744
Min. Negotiated Rate	$3,395.58
Max. Negotiated Rate	$16,488.00
Rate for Payer: Affinity Essential Plan 1&2	$3,395.58
Rate for Payer: Affinity Essential Plan 3&4	$3,395.58
Rate for Payer: Affinity Medicaid/CHP/HARP	$3,395.58
Rate for Payer: Carelon Behavioral Health HARP/QHP	$3,395.58
Rate for Payer: EmblemHealth Essential Plan 1&2	$7,640.06
Rate for Payer: EmblemHealth Essential Plan 3&4	$3,395.58
Rate for Payer: Fidelis Qualified Health Plan	$4,074.70
Rate for Payer: Hamaspik Choice Inc Medicaid	$3,395.58
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$3,395.58
Rate for Payer: Healthfirst Commercial	$16,488.00
Rate for Payer: Healthfirst Essential Plan	$7,640.06
Rate for Payer: Healthfirst QHP	$6,179.96
Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid	$3,395.58
Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa)	$7,640.06
Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa)	$7,640.06
Rate for Payer: SOMOS CHP/HARP/Medicaid	$3,395.58
Rate for Payer: SOMOS Essential	$7,640.06
Rate for Payer: United Healthcare Essential Plan 1&2	$7,640.06
Rate for Payer: United Healthcare Essential Plan 3&4	$7,640.06
Rate for Payer: United Healthcare Medicaid	$3,395.58

Cocaine abuse & dependence

Facility

$10,896.00

Service Code	APR-DRG 7742
Min. Negotiated Rate	$3,379.06
Max. Negotiated Rate	$10,896.00
Rate for Payer: Affinity Essential Plan 1&2	$3,379.06
Rate for Payer: Affinity Essential Plan 3&4	$3,379.06
Rate for Payer: Affinity Medicaid/CHP/HARP	$3,379.06
Rate for Payer: Carelon Behavioral Health HARP/QHP	$3,379.06
Rate for Payer: EmblemHealth Essential Plan 1&2	$7,602.89
Rate for Payer: EmblemHealth Essential Plan 3&4	$3,379.06
Rate for Payer: Fidelis Qualified Health Plan	$4,054.87
Rate for Payer: Hamaspik Choice Inc Medicaid	$3,379.06
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$3,379.06
Rate for Payer: Healthfirst Commercial	$10,896.00
Rate for Payer: Healthfirst Essential Plan	$7,602.89
Rate for Payer: Healthfirst QHP	$6,149.89
Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid	$3,379.06
Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa)	$7,602.89
Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa)	$7,602.89
Rate for Payer: SOMOS CHP/HARP/Medicaid	$3,379.06
Rate for Payer: SOMOS Essential	$7,602.89
Rate for Payer: United Healthcare Essential Plan 1&2	$7,602.89
Rate for Payer: United Healthcare Essential Plan 3&4	$7,602.89
Rate for Payer: United Healthcare Medicaid	$3,379.06

COCAINE HCL 40 MG/ML NA SOLN

Facility

$88.20

Service Code	NDC 7083936204
Hospital Charge Code	7083936204
Hospital Revenue Code	250
Min. Negotiated Rate	$44.10
Max. Negotiated Rate	$44.10
Rate for Payer: Hamaspik Choice Inc Medicaid	$44.10

COCAINE HCL 40 MG/ML NA SOLN

Facility

$73.50

Service Code	NDC 6495036204
Hospital Charge Code	6495036204
Hospital Revenue Code	250
Min. Negotiated Rate	$36.75
Max. Negotiated Rate	$36.75
Rate for Payer: Hamaspik Choice Inc Medicaid	$36.75

COCAINE HCL 40 MG/ML NA SOLN

Facility

$88.20

Service Code	NDC 7083936204
Hospital Charge Code	7083936204
Hospital Revenue Code	250
Min. Negotiated Rate	$30.87
Max. Negotiated Rate	$70.56
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$48.51
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$44.10
Rate for Payer: Aetna Government	$44.10
Rate for Payer: Brighton Health Commercial	$66.15
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$70.56
Rate for Payer: Cigna LocalPlus Benefit Plan	$59.98
Rate for Payer: EmblemHealth Commercial	$44.10
Rate for Payer: Group Health Inc Commercial	$44.10
Rate for Payer: Group Health Inc Medicare	$30.87
Rate for Payer: Hamaspik Choice Inc Medicaid	$44.10
Rate for Payer: Hamaspik Choice Inc Medicare	$44.10
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$57.33

COCAINE HCL 40 MG/ML NA SOLN

Facility

$73.50

Service Code	NDC 6495036204
Hospital Charge Code	6495036204
Hospital Revenue Code	250
Min. Negotiated Rate	$25.73
Max. Negotiated Rate	$58.80
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$40.42
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$36.75
Rate for Payer: Aetna Government	$36.75
Rate for Payer: Brighton Health Commercial	$55.12
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$58.80
Rate for Payer: Cigna LocalPlus Benefit Plan	$49.98
Rate for Payer: EmblemHealth Commercial	$36.75
Rate for Payer: Group Health Inc Commercial	$36.75
Rate for Payer: Group Health Inc Medicare	$25.73
Rate for Payer: Hamaspik Choice Inc Medicaid	$36.75
Rate for Payer: Hamaspik Choice Inc Medicare	$36.75
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$47.77

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