|
AZTREONAM 1 G IJ SOLR [9185]
|
Facility
|
OP
|
$43.30
|
|
|
Service Code
|
HCPCS J7512
|
| Hospital Charge Code |
63323040101
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$34.64 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$23.81
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.02
|
| Rate for Payer: Aetna Government |
$0.02
|
| Rate for Payer: Brighton Health Commercial |
$32.47
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$34.64
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$29.44
|
| Rate for Payer: Group Health Inc Commercial |
$21.65
|
| Rate for Payer: Group Health Inc Medicare |
$15.15
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$21.65
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$21.65
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$0.01
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$0.01
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$0.01
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$0.01
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$28.14
|
|
|
AZTREONAM 1 G IJ SOLR [9185]
|
Facility
|
OP
|
$32.77
|
|
|
Service Code
|
HCPCS J7512
|
| Hospital Charge Code |
63323040124
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$26.22 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$18.02
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.02
|
| Rate for Payer: Aetna Government |
$0.02
|
| Rate for Payer: Brighton Health Commercial |
$24.58
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$26.22
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$22.28
|
| Rate for Payer: Group Health Inc Commercial |
$16.39
|
| Rate for Payer: Group Health Inc Medicare |
$11.47
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$16.39
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$16.39
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$0.01
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$0.01
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$0.01
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$0.01
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$21.30
|
|
|
AZTREONAM 1 G IJ SOLR [9185]
|
Facility
|
OP
|
$43.30
|
|
|
Service Code
|
HCPCS J7512
|
| Hospital Charge Code |
63323040120
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$34.64 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$23.81
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.02
|
| Rate for Payer: Aetna Government |
$0.02
|
| Rate for Payer: Brighton Health Commercial |
$32.47
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$34.64
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$29.44
|
| Rate for Payer: Group Health Inc Commercial |
$21.65
|
| Rate for Payer: Group Health Inc Medicare |
$15.15
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$21.65
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$21.65
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$0.01
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$0.01
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$0.01
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$0.01
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$28.14
|
|
|
AZTREONAM 1 G IJ SOLR [9185]
|
Facility
|
OP
|
$35.67
|
|
|
Service Code
|
HCPCS J7512
|
| Hospital Charge Code |
00003256016
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$28.54 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$19.62
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.02
|
| Rate for Payer: Aetna Government |
$0.02
|
| Rate for Payer: Brighton Health Commercial |
$26.75
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$28.54
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$24.26
|
| Rate for Payer: Group Health Inc Commercial |
$17.84
|
| Rate for Payer: Group Health Inc Medicare |
$12.48
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$17.84
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$17.84
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$0.01
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$0.01
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$0.01
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$0.01
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$23.19
|
|
|
AZTREONAM 2000 MG INJ
|
Facility
|
OP
|
$101.01
|
|
| Hospital Charge Code |
41655545
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$35.35 |
| Max. Negotiated Rate |
$80.81 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$55.56
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$50.50
|
| Rate for Payer: Aetna Government |
$50.50
|
| Rate for Payer: Brighton Health Commercial |
$75.76
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$80.81
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$68.69
|
| Rate for Payer: Group Health Inc Commercial |
$50.50
|
| Rate for Payer: Group Health Inc Medicare |
$35.35
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$50.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$50.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$65.66
|
|
|
AZTREONAM 2000 MG INJ
|
Facility
|
OP
|
$101.01
|
|
| Hospital Charge Code |
41645545
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$35.35 |
| Max. Negotiated Rate |
$80.81 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$55.56
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$50.50
|
| Rate for Payer: Aetna Government |
$50.50
|
| Rate for Payer: Brighton Health Commercial |
$75.76
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$80.81
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$68.69
|
| Rate for Payer: Group Health Inc Commercial |
$50.50
|
| Rate for Payer: Group Health Inc Medicare |
$35.35
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$50.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$50.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$65.66
|
|
|
AZTREONAM 20MG/ML NS
|
Facility
|
IP
|
$2.16
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
41650284
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.08 |
| Max. Negotiated Rate |
$1.08 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.08
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.08
|
|
|
AZTREONAM 20MG/ML NS
|
Facility
|
OP
|
$2.16
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
41640284
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.76 |
| Max. Negotiated Rate |
$1.40 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.19
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.08
|
| Rate for Payer: Aetna Government |
$1.08
|
| Rate for Payer: Brighton Health Commercial |
$1.30
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.08
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.24
|
| Rate for Payer: Group Health Inc Commercial |
$1.08
|
| Rate for Payer: Group Health Inc Medicare |
$0.76
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.08
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.08
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.40
|
|
|
AZTREONAM 20MG/ML NS
|
Facility
|
IP
|
$2.16
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
41640284
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.08 |
| Max. Negotiated Rate |
$1.08 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.08
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.08
|
|
|
AZTREONAM 20MG/ML NS
|
Facility
|
OP
|
$2.16
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
41650284
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.76 |
| Max. Negotiated Rate |
$1.40 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.19
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.08
|
| Rate for Payer: Aetna Government |
$1.08
|
| Rate for Payer: Brighton Health Commercial |
$1.30
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.08
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.24
|
| Rate for Payer: Group Health Inc Commercial |
$1.08
|
| Rate for Payer: Group Health Inc Medicare |
$0.76
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.08
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.08
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.40
|
|
|
AZTREONAM 2G/D5W 50ML IVPB
|
Facility
|
OP
|
$48.00
|
|
| Hospital Charge Code |
41654304
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.80 |
| Max. Negotiated Rate |
$38.40 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$26.40
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$24.00
|
| Rate for Payer: Aetna Government |
$24.00
|
| Rate for Payer: Brighton Health Commercial |
$36.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$38.40
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$32.64
|
| Rate for Payer: Group Health Inc Commercial |
$24.00
|
| Rate for Payer: Group Health Inc Medicare |
$16.80
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$24.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$24.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$31.20
|
|
|
AZTREONAM 2G/D5W 50ML IVPB
|
Facility
|
OP
|
$48.00
|
|
| Hospital Charge Code |
41644304
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.80 |
| Max. Negotiated Rate |
$38.40 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$26.40
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$24.00
|
| Rate for Payer: Aetna Government |
$24.00
|
| Rate for Payer: Brighton Health Commercial |
$36.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$38.40
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$32.64
|
| Rate for Payer: Group Health Inc Commercial |
$24.00
|
| Rate for Payer: Group Health Inc Medicare |
$16.80
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$24.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$24.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$31.20
|
|
|
AZTREONAM 2 G IJ SOLR [9186]
|
Facility
|
OP
|
$87.97
|
|
|
Service Code
|
HCPCS J0457
|
| Hospital Charge Code |
63323040220
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.78 |
| Max. Negotiated Rate |
$70.38 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$48.38
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.54
|
| Rate for Payer: Aetna Government |
$2.54
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$1.78
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$1.78
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$1.78
|
| Rate for Payer: Brighton Health Commercial |
$65.98
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$2.54
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$70.38
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$59.82
|
| Rate for Payer: Elderplan Medicare Advantage |
$2.54
|
| Rate for Payer: EmblemHealth Commercial |
$2.54
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$2.16
|
| Rate for Payer: Fidelis Essential Plan QHP |
$2.26
|
| Rate for Payer: Fidelis Medicare Advantage |
$2.54
|
| Rate for Payer: Fidelis Qualified Health Plan |
$2.26
|
| Rate for Payer: Group Health Inc Commercial |
$2.54
|
| Rate for Payer: Group Health Inc Medicare |
$2.54
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$43.99
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2.54
|
| Rate for Payer: Healthfirst Medicare Advantage |
$2.16
|
| Rate for Payer: Healthfirst QHP |
$2.54
|
| Rate for Payer: Humana Medicare |
$2.59
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$2.58
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$2.73
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$2.73
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$2.73
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$2.54
|
| Rate for Payer: United Healthcare Medicare Advantage |
$2.54
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$57.18
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$2.03
|
| Rate for Payer: Wellcare Medicare |
$2.41
|
|
|
AZTREONAM 2 G IJ SOLR [9186]
|
Facility
|
OP
|
$65.54
|
|
|
Service Code
|
HCPCS J0457
|
| Hospital Charge Code |
63323040224
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.78 |
| Max. Negotiated Rate |
$52.44 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$36.05
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.54
|
| Rate for Payer: Aetna Government |
$2.54
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$1.78
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$1.78
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$1.78
|
| Rate for Payer: Brighton Health Commercial |
$49.16
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$2.54
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$52.44
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$44.57
|
| Rate for Payer: Elderplan Medicare Advantage |
$2.54
|
| Rate for Payer: EmblemHealth Commercial |
$2.54
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$2.16
|
| Rate for Payer: Fidelis Essential Plan QHP |
$2.26
|
| Rate for Payer: Fidelis Medicare Advantage |
$2.54
|
| Rate for Payer: Fidelis Qualified Health Plan |
$2.26
|
| Rate for Payer: Group Health Inc Commercial |
$2.54
|
| Rate for Payer: Group Health Inc Medicare |
$2.54
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$32.77
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2.54
|
| Rate for Payer: Healthfirst Medicare Advantage |
$2.16
|
| Rate for Payer: Healthfirst QHP |
$2.54
|
| Rate for Payer: Humana Medicare |
$2.59
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$2.58
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$2.73
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$2.73
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$2.73
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$2.54
|
| Rate for Payer: United Healthcare Medicare Advantage |
$2.54
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$42.60
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$2.03
|
| Rate for Payer: Wellcare Medicare |
$2.41
|
|
|
AZTREONAM 2 G IJ SOLR [9186]
|
Facility
|
OP
|
$71.34
|
|
|
Service Code
|
HCPCS J0457
|
| Hospital Charge Code |
00003257016
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.78 |
| Max. Negotiated Rate |
$57.07 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$39.24
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.54
|
| Rate for Payer: Aetna Government |
$2.54
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$1.78
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$1.78
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$1.78
|
| Rate for Payer: Brighton Health Commercial |
$53.50
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$2.54
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$57.07
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$48.51
|
| Rate for Payer: Elderplan Medicare Advantage |
$2.54
|
| Rate for Payer: EmblemHealth Commercial |
$2.54
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$2.16
|
| Rate for Payer: Fidelis Essential Plan QHP |
$2.26
|
| Rate for Payer: Fidelis Medicare Advantage |
$2.54
|
| Rate for Payer: Fidelis Qualified Health Plan |
$2.26
|
| Rate for Payer: Group Health Inc Commercial |
$2.54
|
| Rate for Payer: Group Health Inc Medicare |
$2.54
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$35.67
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2.54
|
| Rate for Payer: Healthfirst Medicare Advantage |
$2.16
|
| Rate for Payer: Healthfirst QHP |
$2.54
|
| Rate for Payer: Humana Medicare |
$2.59
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$2.58
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$2.73
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$2.73
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$2.73
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$2.54
|
| Rate for Payer: United Healthcare Medicare Advantage |
$2.54
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$46.37
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$2.03
|
| Rate for Payer: Wellcare Medicare |
$2.41
|
|
|
AZTREONAM 2 G IJ SOLR [9186]
|
Facility
|
OP
|
$78.00
|
|
|
Service Code
|
HCPCS J0457
|
| Hospital Charge Code |
00409083001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.78 |
| Max. Negotiated Rate |
$62.40 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$42.90
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.54
|
| Rate for Payer: Aetna Government |
$2.54
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$1.78
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$1.78
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$1.78
|
| Rate for Payer: Brighton Health Commercial |
$58.50
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$2.54
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$62.40
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$53.04
|
| Rate for Payer: Elderplan Medicare Advantage |
$2.54
|
| Rate for Payer: EmblemHealth Commercial |
$2.54
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$2.16
|
| Rate for Payer: Fidelis Essential Plan QHP |
$2.26
|
| Rate for Payer: Fidelis Medicare Advantage |
$2.54
|
| Rate for Payer: Fidelis Qualified Health Plan |
$2.26
|
| Rate for Payer: Group Health Inc Commercial |
$2.54
|
| Rate for Payer: Group Health Inc Medicare |
$2.54
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$39.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2.54
|
| Rate for Payer: Healthfirst Medicare Advantage |
$2.16
|
| Rate for Payer: Healthfirst QHP |
$2.54
|
| Rate for Payer: Humana Medicare |
$2.59
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$2.58
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$2.73
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$2.73
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$2.73
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$2.54
|
| Rate for Payer: United Healthcare Medicare Advantage |
$2.54
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$50.70
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$2.03
|
| Rate for Payer: Wellcare Medicare |
$2.41
|
|
|
AZTREONAM 2 G IJ SOLR [9186]
|
Facility
|
OP
|
$87.97
|
|
|
Service Code
|
HCPCS J0457
|
| Hospital Charge Code |
63323040201
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.78 |
| Max. Negotiated Rate |
$70.38 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$48.38
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.54
|
| Rate for Payer: Aetna Government |
$2.54
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$1.78
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$1.78
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$1.78
|
| Rate for Payer: Brighton Health Commercial |
$65.98
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$2.54
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$70.38
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$59.82
|
| Rate for Payer: Elderplan Medicare Advantage |
$2.54
|
| Rate for Payer: EmblemHealth Commercial |
$2.54
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$2.16
|
| Rate for Payer: Fidelis Essential Plan QHP |
$2.26
|
| Rate for Payer: Fidelis Medicare Advantage |
$2.54
|
| Rate for Payer: Fidelis Qualified Health Plan |
$2.26
|
| Rate for Payer: Group Health Inc Commercial |
$2.54
|
| Rate for Payer: Group Health Inc Medicare |
$2.54
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$43.99
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2.54
|
| Rate for Payer: Healthfirst Medicare Advantage |
$2.16
|
| Rate for Payer: Healthfirst QHP |
$2.54
|
| Rate for Payer: Humana Medicare |
$2.59
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$2.58
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$2.73
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$2.73
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$2.73
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$2.54
|
| Rate for Payer: United Healthcare Medicare Advantage |
$2.54
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$57.18
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$2.03
|
| Rate for Payer: Wellcare Medicare |
$2.41
|
|
|
AZTREONAM 500MG/D5W ML IVPB
|
Facility
|
IP
|
$14.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
41658028
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.00 |
| Max. Negotiated Rate |
$7.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$7.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$7.00
|
|
|
AZTREONAM 500MG/D5W ML IVPB
|
Facility
|
OP
|
$14.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
41658028
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.90 |
| Max. Negotiated Rate |
$9.10 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$7.70
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$7.00
|
| Rate for Payer: Aetna Government |
$7.00
|
| Rate for Payer: Brighton Health Commercial |
$8.40
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$7.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$8.05
|
| Rate for Payer: Group Health Inc Commercial |
$7.00
|
| Rate for Payer: Group Health Inc Medicare |
$4.90
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$7.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$7.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$9.10
|
|
|
AZTREONAM 500MG/D5W ML IVPB
|
Facility
|
OP
|
$14.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
41648028
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.90 |
| Max. Negotiated Rate |
$9.10 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$7.70
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$7.00
|
| Rate for Payer: Aetna Government |
$7.00
|
| Rate for Payer: Brighton Health Commercial |
$8.40
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$7.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$8.05
|
| Rate for Payer: Group Health Inc Commercial |
$7.00
|
| Rate for Payer: Group Health Inc Medicare |
$4.90
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$7.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$7.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$9.10
|
|
|
AZTREONAM 500MG/D5W ML IVPB
|
Facility
|
IP
|
$14.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
41648028
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.00 |
| Max. Negotiated Rate |
$7.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$7.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$7.00
|
|
|
AZTREONAM IVP < 2000MG
|
Facility
|
IP
|
$33.80
|
|
|
Service Code
|
HCPCS S0073
|
| Hospital Charge Code |
41647824
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.90 |
| Max. Negotiated Rate |
$16.90 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$16.90
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$16.90
|
|
|
AZTREONAM IVP < 2000MG
|
Facility
|
IP
|
$33.80
|
|
|
Service Code
|
HCPCS S0073
|
| Hospital Charge Code |
41647825
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.90 |
| Max. Negotiated Rate |
$16.90 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$16.90
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$16.90
|
|
|
AZTREONAM IVP < 2000MG
|
Facility
|
OP
|
$33.80
|
|
|
Service Code
|
HCPCS S0073
|
| Hospital Charge Code |
41657825
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.83 |
| Max. Negotiated Rate |
$21.97 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$18.59
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$12.01
|
| Rate for Payer: Aetna Government |
$12.01
|
| Rate for Payer: Brighton Health Commercial |
$20.28
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$16.90
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$19.44
|
| Rate for Payer: Group Health Inc Commercial |
$16.90
|
| Rate for Payer: Group Health Inc Medicare |
$11.83
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$16.90
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$16.90
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$21.97
|
|
|
AZTREONAM IVP < 2000MG
|
Facility
|
OP
|
$33.80
|
|
|
Service Code
|
HCPCS S0073
|
| Hospital Charge Code |
41647825
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.83 |
| Max. Negotiated Rate |
$21.97 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$18.59
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$12.01
|
| Rate for Payer: Aetna Government |
$12.01
|
| Rate for Payer: Brighton Health Commercial |
$20.28
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$16.90
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$19.44
|
| Rate for Payer: Group Health Inc Commercial |
$16.90
|
| Rate for Payer: Group Health Inc Medicare |
$11.83
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$16.90
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$16.90
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$21.97
|
|
