|
BEHAVIORAL HEALTH SCREENING
|
Facility
|
OP
|
$450.70
|
|
|
Service Code
|
HCPCS H0002
|
| Hospital Charge Code |
30400239
|
|
Hospital Revenue Code
|
900
|
| Min. Negotiated Rate |
$45.78 |
| Max. Negotiated Rate |
$360.56 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$247.88
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$45.78
|
| Rate for Payer: Aetna Government |
$45.78
|
| Rate for Payer: Brighton Health Commercial |
$338.02
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$360.56
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$306.48
|
| Rate for Payer: Group Health Inc Commercial |
$225.35
|
| Rate for Payer: Group Health Inc Medicare |
$157.74
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$225.35
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$225.35
|
| Rate for Payer: United Healthcare Commercial |
$225.35
|
|
|
BEHAVIOR COUNSEL OBESITY 15 MIN
|
Facility
|
OP
|
$237.88
|
|
|
Service Code
|
HCPCS G0447
|
| Hospital Charge Code |
30305579
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$72.16 |
| Max. Negotiated Rate |
$250.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$130.83
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$103.08
|
| Rate for Payer: Aetna Government |
$103.08
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$72.16
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$72.16
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$72.16
|
| Rate for Payer: Brighton Health Commercial |
$233.00
|
| Rate for Payer: Cash Price |
$103.08
|
| Rate for Payer: Cash Price |
$103.08
|
| Rate for Payer: Cash Price |
$103.08
|
| Rate for Payer: Cash Price |
$103.08
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$103.08
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$204.58
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$173.89
|
| Rate for Payer: Elderplan Medicare Advantage |
$103.08
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$87.62
|
| Rate for Payer: Fidelis Essential Plan QHP |
$91.74
|
| Rate for Payer: Fidelis Medicare Advantage |
$103.08
|
| Rate for Payer: Fidelis Qualified Health Plan |
$91.74
|
| Rate for Payer: Group Health Inc Commercial |
$250.00
|
| Rate for Payer: Group Health Inc Medicare |
$250.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$118.94
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$103.08
|
| Rate for Payer: Healthfirst Medicare Advantage |
$87.62
|
| Rate for Payer: Healthfirst QHP |
$103.08
|
| Rate for Payer: Humana Medicare |
$105.14
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$103.08
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$103.08
|
| Rate for Payer: United Healthcare Commercial |
$222.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$103.08
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$103.08
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$82.46
|
| Rate for Payer: Wellcare Medicare |
$97.93
|
|
|
BEHAVIOR COUNSEL OBESITY 15 MIN
|
Facility
|
IP
|
$237.88
|
|
|
Service Code
|
HCPCS G0447
|
| Hospital Charge Code |
30305579
|
|
Hospital Revenue Code
|
510
|
| Rate for Payer: Cash Price |
$103.08
|
|
|
BEHAVIOR MANAGEMENT,BY REPORT
|
Facility
|
OP
|
$72.50
|
|
|
Service Code
|
HCPCS D9920
|
| Hospital Charge Code |
42300757
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$25.38 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$39.88
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$27.32
|
| Rate for Payer: Aetna Government |
$27.32
|
| Rate for Payer: Brighton Health Commercial |
$54.38
|
| 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: Group Health Inc Commercial |
$36.25
|
| Rate for Payer: Group Health Inc Medicare |
$25.38
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$36.25
|
|
|
BEHAVIOR SESSION EACH ADDL 15MINS
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
HCPCS 96165
|
| Hospital Charge Code |
30300362
|
|
Hospital Revenue Code
|
915
|
| Max. Negotiated Rate |
$1,452.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.01
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3.22
|
| Rate for Payer: Aetna Government |
$3.22
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$32.67
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$32.67
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$14.52
|
| Rate for Payer: Amida Care Medicaid |
$14.52
|
| Rate for Payer: Brighton Health Commercial |
$0.01
|
| Rate for Payer: Carelon Behavioral Health HARP/QHP |
$14.65
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.01
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.01
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$1,452.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$14.52
|
| Rate for Payer: Fidelis Essential Plan QHP |
$14.52
|
| Rate for Payer: Fidelis Qualified Health Plan |
$15.25
|
| Rate for Payer: Group Health Inc Commercial |
$0.01
|
| Rate for Payer: Group Health Inc Medicare |
$0.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$14.52
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.01
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$14.52
|
| Rate for Payer: Healthfirst Essential Plan |
$32.67
|
| Rate for Payer: Healthfirst QHP |
$14.52
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$14.65
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$32.96
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$32.96
|
| Rate for Payer: Optum Medicaid |
$14.65
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$14.52
|
| Rate for Payer: SOMOS Essential |
$32.67
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$32.67
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$15.97
|
| Rate for Payer: United Healthcare Medicaid |
$14.52
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$14.52
|
|
|
BEHAVIOR SMG CHANGE 10 MIN
|
Facility
|
IP
|
$82.75
|
|
|
Service Code
|
HCPCS 99407
|
| Hospital Charge Code |
30400244
|
|
Hospital Revenue Code
|
942
|
| Rate for Payer: Cash Price |
$33.18
|
|
|
BEHAVIOR SMG CHANGE 10 MIN
|
Facility
|
OP
|
$82.75
|
|
|
Service Code
|
HCPCS 99407
|
| Hospital Charge Code |
30400244
|
|
Hospital Revenue Code
|
942
|
| Min. Negotiated Rate |
$23.23 |
| Max. Negotiated Rate |
$250.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$45.51
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$33.18
|
| Rate for Payer: Aetna Government |
$33.18
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$23.23
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$23.23
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$23.23
|
| Rate for Payer: Brighton Health Commercial |
$62.06
|
| Rate for Payer: Cash Price |
$33.18
|
| Rate for Payer: Cash Price |
$33.18
|
| Rate for Payer: Cash Price |
$33.18
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$33.18
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$66.20
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$56.27
|
| Rate for Payer: Elderplan Medicare Advantage |
$33.18
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$28.20
|
| Rate for Payer: Fidelis Essential Plan QHP |
$29.53
|
| Rate for Payer: Fidelis Medicare Advantage |
$33.18
|
| Rate for Payer: Fidelis Qualified Health Plan |
$29.53
|
| Rate for Payer: Group Health Inc Commercial |
$250.00
|
| Rate for Payer: Group Health Inc Medicare |
$250.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$41.38
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$33.18
|
| Rate for Payer: Healthfirst Medicare Advantage |
$28.20
|
| Rate for Payer: Healthfirst QHP |
$33.18
|
| Rate for Payer: Humana Medicare |
$33.84
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$33.18
|
| Rate for Payer: United Healthcare Commercial |
$41.38
|
| Rate for Payer: United Healthcare Medicare Advantage |
$33.18
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$33.18
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$26.54
|
| Rate for Payer: Wellcare Medicare |
$31.52
|
|
|
BEHAVIOR SMG CHANGE 30-10 MIN
|
Facility
|
IP
|
$82.75
|
|
|
Service Code
|
HCPCS 99406
|
| Hospital Charge Code |
30400243
|
|
Hospital Revenue Code
|
942
|
| Rate for Payer: Cash Price |
$33.18
|
|
|
BEHAVIOR SMG CHANGE 30-10 MIN
|
Facility
|
OP
|
$82.75
|
|
|
Service Code
|
HCPCS 99406
|
| Hospital Charge Code |
30400243
|
|
Hospital Revenue Code
|
942
|
| Min. Negotiated Rate |
$23.23 |
| Max. Negotiated Rate |
$250.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$45.51
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$33.18
|
| Rate for Payer: Aetna Government |
$33.18
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$23.23
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$23.23
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$23.23
|
| Rate for Payer: Brighton Health Commercial |
$62.06
|
| Rate for Payer: Cash Price |
$33.18
|
| Rate for Payer: Cash Price |
$33.18
|
| Rate for Payer: Cash Price |
$33.18
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$33.18
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$66.20
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$56.27
|
| Rate for Payer: Elderplan Medicare Advantage |
$33.18
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$28.20
|
| Rate for Payer: Fidelis Essential Plan QHP |
$29.53
|
| Rate for Payer: Fidelis Medicare Advantage |
$33.18
|
| Rate for Payer: Fidelis Qualified Health Plan |
$29.53
|
| Rate for Payer: Group Health Inc Commercial |
$250.00
|
| Rate for Payer: Group Health Inc Medicare |
$250.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$41.38
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$33.18
|
| Rate for Payer: Healthfirst Medicare Advantage |
$28.20
|
| Rate for Payer: Healthfirst QHP |
$33.18
|
| Rate for Payer: Humana Medicare |
$33.84
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$33.18
|
| Rate for Payer: United Healthcare Commercial |
$41.38
|
| Rate for Payer: United Healthcare Medicare Advantage |
$33.18
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$33.18
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$26.54
|
| Rate for Payer: Wellcare Medicare |
$31.52
|
|
|
BELIMUMAB 120 MG IV SOLR [108842]
|
Facility
|
OP
|
$735.72
|
|
|
Service Code
|
HCPCS J0490
|
| Hospital Charge Code |
49401010101
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$40.95 |
| Max. Negotiated Rate |
$4,095.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$404.65
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$52.00
|
| Rate for Payer: Aetna Government |
$52.00
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$92.14
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$92.14
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$40.95
|
| Rate for Payer: Amida Care Medicaid |
$40.95
|
| Rate for Payer: Brighton Health Commercial |
$441.43
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$52.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$367.86
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$423.04
|
| Rate for Payer: Elderplan Medicare Advantage |
$52.00
|
| Rate for Payer: EmblemHealth Commercial |
$367.86
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$4,095.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$40.95
|
| Rate for Payer: Fidelis Essential Plan QHP |
$40.95
|
| Rate for Payer: Fidelis Medicare Advantage |
$52.00
|
| Rate for Payer: Fidelis Qualified Health Plan |
$43.00
|
| Rate for Payer: Group Health Inc Commercial |
$52.00
|
| Rate for Payer: Group Health Inc Medicare |
$52.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$40.95
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$367.86
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$40.95
|
| Rate for Payer: Healthfirst Essential Plan |
$92.14
|
| Rate for Payer: Healthfirst Medicare Advantage |
$44.20
|
| Rate for Payer: Healthfirst QHP |
$40.95
|
| Rate for Payer: Humana Medicare |
$53.04
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$52.00
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$40.95
|
| Rate for Payer: SOMOS Essential |
$40.95
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$92.14
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$45.04
|
| Rate for Payer: United Healthcare Medicaid |
$40.95
|
| Rate for Payer: United Healthcare Medicare Advantage |
$52.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$478.22
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$41.60
|
|
|
BELIMUMAB 120 MG IV SOLR [108842]
|
Facility
|
IP
|
$735.72
|
|
|
Service Code
|
HCPCS J0490
|
| Hospital Charge Code |
49401010101
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$367.86 |
| Max. Negotiated Rate |
$367.86 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$367.86
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$367.86
|
|
|
BELIMUMAB 400 MG IV SOLR [108843]
|
Facility
|
IP
|
$2,452.28
|
|
|
Service Code
|
HCPCS J0490
|
| Hospital Charge Code |
49401010201
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,226.14 |
| Max. Negotiated Rate |
$1,226.14 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,226.14
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,226.14
|
|
|
BELIMUMAB 400 MG IV SOLR [108843]
|
Facility
|
OP
|
$2,452.28
|
|
|
Service Code
|
HCPCS J0490
|
| Hospital Charge Code |
49401010201
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$40.95 |
| Max. Negotiated Rate |
$4,095.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,348.75
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$52.00
|
| Rate for Payer: Aetna Government |
$52.00
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$92.14
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$92.14
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$40.95
|
| Rate for Payer: Amida Care Medicaid |
$40.95
|
| Rate for Payer: Brighton Health Commercial |
$1,471.37
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$52.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,226.14
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,410.06
|
| Rate for Payer: Elderplan Medicare Advantage |
$52.00
|
| Rate for Payer: EmblemHealth Commercial |
$1,226.14
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$4,095.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$40.95
|
| Rate for Payer: Fidelis Essential Plan QHP |
$40.95
|
| Rate for Payer: Fidelis Medicare Advantage |
$52.00
|
| Rate for Payer: Fidelis Qualified Health Plan |
$43.00
|
| Rate for Payer: Group Health Inc Commercial |
$52.00
|
| Rate for Payer: Group Health Inc Medicare |
$52.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$40.95
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,226.14
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$40.95
|
| Rate for Payer: Healthfirst Essential Plan |
$92.14
|
| Rate for Payer: Healthfirst Medicare Advantage |
$44.20
|
| Rate for Payer: Healthfirst QHP |
$40.95
|
| Rate for Payer: Humana Medicare |
$53.04
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$52.00
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$40.95
|
| Rate for Payer: SOMOS Essential |
$40.95
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$92.14
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$45.04
|
| Rate for Payer: United Healthcare Medicaid |
$40.95
|
| Rate for Payer: United Healthcare Medicare Advantage |
$52.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,593.98
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$41.60
|
|
|
BELIMUMAB PD VIAL 120MG
|
Facility
|
OP
|
$55.83
|
|
|
Service Code
|
HCPCS J0490
|
| Hospital Charge Code |
41650278
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$27.92 |
| Max. Negotiated Rate |
$4,095.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$30.71
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$52.00
|
| Rate for Payer: Aetna Government |
$52.00
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$92.14
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$92.14
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$40.95
|
| Rate for Payer: Amida Care Medicaid |
$40.95
|
| Rate for Payer: Brighton Health Commercial |
$33.50
|
| Rate for Payer: Cash Price |
$52.00
|
| Rate for Payer: Cash Price |
$52.00
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$52.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$27.92
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$32.10
|
| Rate for Payer: Elderplan Medicare Advantage |
$52.00
|
| Rate for Payer: EmblemHealth Commercial |
$52.00
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$4,095.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$40.95
|
| Rate for Payer: Fidelis Essential Plan QHP |
$40.95
|
| Rate for Payer: Fidelis Medicare Advantage |
$52.00
|
| Rate for Payer: Fidelis Qualified Health Plan |
$43.00
|
| Rate for Payer: Group Health Inc Commercial |
$52.00
|
| Rate for Payer: Group Health Inc Medicare |
$52.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$40.95
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$27.92
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$40.95
|
| Rate for Payer: Healthfirst Essential Plan |
$92.14
|
| Rate for Payer: Healthfirst Medicare Advantage |
$44.20
|
| Rate for Payer: Healthfirst QHP |
$40.95
|
| Rate for Payer: Humana Medicare |
$53.04
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$52.00
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$40.95
|
| Rate for Payer: SOMOS Essential |
$40.95
|
| Rate for Payer: United Healthcare Commercial |
$50.20
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$92.14
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$45.04
|
| Rate for Payer: United Healthcare Medicaid |
$40.95
|
| Rate for Payer: United Healthcare Medicare Advantage |
$52.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$36.29
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$41.60
|
| Rate for Payer: Wellcare Medicare |
$49.40
|
|
|
BELIMUMAB PD VIAL 120MG
|
Facility
|
IP
|
$55.83
|
|
|
Service Code
|
HCPCS J0490
|
| Hospital Charge Code |
41650278
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$27.92 |
| Max. Negotiated Rate |
$27.92 |
| Rate for Payer: Cash Price |
$52.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$27.92
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$27.92
|
|
|
BELIMUMAB PD VIAL 120MG
|
Facility
|
OP
|
$55.83
|
|
|
Service Code
|
HCPCS J0490
|
| Hospital Charge Code |
41640278
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$27.92 |
| Max. Negotiated Rate |
$4,095.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$30.71
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$52.00
|
| Rate for Payer: Aetna Government |
$52.00
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$92.14
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$92.14
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$40.95
|
| Rate for Payer: Amida Care Medicaid |
$40.95
|
| Rate for Payer: Brighton Health Commercial |
$33.50
|
| Rate for Payer: Cash Price |
$52.00
|
| Rate for Payer: Cash Price |
$52.00
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$52.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$27.92
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$32.10
|
| Rate for Payer: Elderplan Medicare Advantage |
$52.00
|
| Rate for Payer: EmblemHealth Commercial |
$52.00
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$4,095.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$40.95
|
| Rate for Payer: Fidelis Essential Plan QHP |
$40.95
|
| Rate for Payer: Fidelis Medicare Advantage |
$52.00
|
| Rate for Payer: Fidelis Qualified Health Plan |
$43.00
|
| Rate for Payer: Group Health Inc Commercial |
$52.00
|
| Rate for Payer: Group Health Inc Medicare |
$52.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$40.95
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$27.92
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$40.95
|
| Rate for Payer: Healthfirst Essential Plan |
$92.14
|
| Rate for Payer: Healthfirst Medicare Advantage |
$44.20
|
| Rate for Payer: Healthfirst QHP |
$40.95
|
| Rate for Payer: Humana Medicare |
$53.04
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$52.00
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$40.95
|
| Rate for Payer: SOMOS Essential |
$40.95
|
| Rate for Payer: United Healthcare Commercial |
$50.20
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$92.14
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$45.04
|
| Rate for Payer: United Healthcare Medicaid |
$40.95
|
| Rate for Payer: United Healthcare Medicare Advantage |
$52.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$36.29
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$41.60
|
| Rate for Payer: Wellcare Medicare |
$49.40
|
|
|
BELIMUMAB PD VIAL 120MG
|
Facility
|
IP
|
$55.83
|
|
|
Service Code
|
HCPCS J0490
|
| Hospital Charge Code |
41640278
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$27.92 |
| Max. Negotiated Rate |
$27.92 |
| Rate for Payer: Cash Price |
$52.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$27.92
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$27.92
|
|
|
BELIMUMAB PD VIAL 200MG
|
Facility
|
IP
|
$49.78
|
|
|
Service Code
|
HCPCS J0490
|
| Hospital Charge Code |
41650277
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.89 |
| Max. Negotiated Rate |
$24.89 |
| Rate for Payer: Cash Price |
$52.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$24.89
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$24.89
|
|
|
BELIMUMAB PD VIAL 200MG
|
Facility
|
OP
|
$49.78
|
|
|
Service Code
|
HCPCS J0490
|
| Hospital Charge Code |
41650277
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.89 |
| Max. Negotiated Rate |
$4,095.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$27.38
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$52.00
|
| Rate for Payer: Aetna Government |
$52.00
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$92.14
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$92.14
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$40.95
|
| Rate for Payer: Amida Care Medicaid |
$40.95
|
| Rate for Payer: Brighton Health Commercial |
$29.87
|
| Rate for Payer: Cash Price |
$52.00
|
| Rate for Payer: Cash Price |
$52.00
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$52.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$24.89
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$28.62
|
| Rate for Payer: Elderplan Medicare Advantage |
$52.00
|
| Rate for Payer: EmblemHealth Commercial |
$52.00
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$4,095.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$40.95
|
| Rate for Payer: Fidelis Essential Plan QHP |
$40.95
|
| Rate for Payer: Fidelis Medicare Advantage |
$52.00
|
| Rate for Payer: Fidelis Qualified Health Plan |
$43.00
|
| Rate for Payer: Group Health Inc Commercial |
$52.00
|
| Rate for Payer: Group Health Inc Medicare |
$52.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$40.95
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$24.89
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$40.95
|
| Rate for Payer: Healthfirst Essential Plan |
$92.14
|
| Rate for Payer: Healthfirst Medicare Advantage |
$44.20
|
| Rate for Payer: Healthfirst QHP |
$40.95
|
| Rate for Payer: Humana Medicare |
$53.04
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$52.00
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$40.95
|
| Rate for Payer: SOMOS Essential |
$40.95
|
| Rate for Payer: United Healthcare Commercial |
$50.20
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$92.14
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$45.04
|
| Rate for Payer: United Healthcare Medicaid |
$40.95
|
| Rate for Payer: United Healthcare Medicare Advantage |
$52.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$32.36
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$41.60
|
| Rate for Payer: Wellcare Medicare |
$49.40
|
|
|
BELIMUMAB PD VIAL 200MG
|
Facility
|
OP
|
$49.78
|
|
|
Service Code
|
HCPCS J0490
|
| Hospital Charge Code |
41640277
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.89 |
| Max. Negotiated Rate |
$4,095.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$27.38
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$52.00
|
| Rate for Payer: Aetna Government |
$52.00
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$92.14
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$92.14
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$40.95
|
| Rate for Payer: Amida Care Medicaid |
$40.95
|
| Rate for Payer: Brighton Health Commercial |
$29.87
|
| Rate for Payer: Cash Price |
$52.00
|
| Rate for Payer: Cash Price |
$52.00
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$52.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$24.89
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$28.62
|
| Rate for Payer: Elderplan Medicare Advantage |
$52.00
|
| Rate for Payer: EmblemHealth Commercial |
$52.00
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$4,095.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$40.95
|
| Rate for Payer: Fidelis Essential Plan QHP |
$40.95
|
| Rate for Payer: Fidelis Medicare Advantage |
$52.00
|
| Rate for Payer: Fidelis Qualified Health Plan |
$43.00
|
| Rate for Payer: Group Health Inc Commercial |
$52.00
|
| Rate for Payer: Group Health Inc Medicare |
$52.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$40.95
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$24.89
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$40.95
|
| Rate for Payer: Healthfirst Essential Plan |
$92.14
|
| Rate for Payer: Healthfirst Medicare Advantage |
$44.20
|
| Rate for Payer: Healthfirst QHP |
$40.95
|
| Rate for Payer: Humana Medicare |
$53.04
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$52.00
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$40.95
|
| Rate for Payer: SOMOS Essential |
$40.95
|
| Rate for Payer: United Healthcare Commercial |
$50.20
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$92.14
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$45.04
|
| Rate for Payer: United Healthcare Medicaid |
$40.95
|
| Rate for Payer: United Healthcare Medicare Advantage |
$52.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$32.36
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$41.60
|
| Rate for Payer: Wellcare Medicare |
$49.40
|
|
|
BELIMUMAB PD VIAL 200MG
|
Facility
|
IP
|
$49.78
|
|
|
Service Code
|
HCPCS J0490
|
| Hospital Charge Code |
41640277
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.89 |
| Max. Negotiated Rate |
$24.89 |
| Rate for Payer: Cash Price |
$52.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$24.89
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$24.89
|
|
|
BELIMUMAB PD VIAL 400MG
|
Facility
|
OP
|
$55.83
|
|
|
Service Code
|
HCPCS J0490
|
| Hospital Charge Code |
41650279
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$27.92 |
| Max. Negotiated Rate |
$4,095.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$30.71
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$52.00
|
| Rate for Payer: Aetna Government |
$52.00
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$92.14
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$92.14
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$40.95
|
| Rate for Payer: Amida Care Medicaid |
$40.95
|
| Rate for Payer: Brighton Health Commercial |
$33.50
|
| Rate for Payer: Cash Price |
$52.00
|
| Rate for Payer: Cash Price |
$52.00
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$52.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$27.92
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$32.10
|
| Rate for Payer: Elderplan Medicare Advantage |
$52.00
|
| Rate for Payer: EmblemHealth Commercial |
$52.00
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$4,095.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$40.95
|
| Rate for Payer: Fidelis Essential Plan QHP |
$40.95
|
| Rate for Payer: Fidelis Medicare Advantage |
$52.00
|
| Rate for Payer: Fidelis Qualified Health Plan |
$43.00
|
| Rate for Payer: Group Health Inc Commercial |
$52.00
|
| Rate for Payer: Group Health Inc Medicare |
$52.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$40.95
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$27.92
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$40.95
|
| Rate for Payer: Healthfirst Essential Plan |
$92.14
|
| Rate for Payer: Healthfirst Medicare Advantage |
$44.20
|
| Rate for Payer: Healthfirst QHP |
$40.95
|
| Rate for Payer: Humana Medicare |
$53.04
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$52.00
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$40.95
|
| Rate for Payer: SOMOS Essential |
$40.95
|
| Rate for Payer: United Healthcare Commercial |
$50.20
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$92.14
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$45.04
|
| Rate for Payer: United Healthcare Medicaid |
$40.95
|
| Rate for Payer: United Healthcare Medicare Advantage |
$52.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$36.29
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$41.60
|
| Rate for Payer: Wellcare Medicare |
$49.40
|
|
|
BELIMUMAB PD VIAL 400MG
|
Facility
|
OP
|
$55.83
|
|
|
Service Code
|
HCPCS J0490
|
| Hospital Charge Code |
41640279
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$27.92 |
| Max. Negotiated Rate |
$4,095.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$30.71
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$52.00
|
| Rate for Payer: Aetna Government |
$52.00
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$92.14
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$92.14
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$40.95
|
| Rate for Payer: Amida Care Medicaid |
$40.95
|
| Rate for Payer: Brighton Health Commercial |
$33.50
|
| Rate for Payer: Cash Price |
$52.00
|
| Rate for Payer: Cash Price |
$52.00
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$52.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$27.92
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$32.10
|
| Rate for Payer: Elderplan Medicare Advantage |
$52.00
|
| Rate for Payer: EmblemHealth Commercial |
$52.00
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$4,095.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$40.95
|
| Rate for Payer: Fidelis Essential Plan QHP |
$40.95
|
| Rate for Payer: Fidelis Medicare Advantage |
$52.00
|
| Rate for Payer: Fidelis Qualified Health Plan |
$43.00
|
| Rate for Payer: Group Health Inc Commercial |
$52.00
|
| Rate for Payer: Group Health Inc Medicare |
$52.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$40.95
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$27.92
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$40.95
|
| Rate for Payer: Healthfirst Essential Plan |
$92.14
|
| Rate for Payer: Healthfirst Medicare Advantage |
$44.20
|
| Rate for Payer: Healthfirst QHP |
$40.95
|
| Rate for Payer: Humana Medicare |
$53.04
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$52.00
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$40.95
|
| Rate for Payer: SOMOS Essential |
$40.95
|
| Rate for Payer: United Healthcare Commercial |
$50.20
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$92.14
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$45.04
|
| Rate for Payer: United Healthcare Medicaid |
$40.95
|
| Rate for Payer: United Healthcare Medicare Advantage |
$52.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$36.29
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$41.60
|
| Rate for Payer: Wellcare Medicare |
$49.40
|
|
|
BELIMUMAB PD VIAL 400MG
|
Facility
|
IP
|
$55.83
|
|
|
Service Code
|
HCPCS J0490
|
| Hospital Charge Code |
41650279
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$27.92 |
| Max. Negotiated Rate |
$27.92 |
| Rate for Payer: Cash Price |
$52.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$27.92
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$27.92
|
|
|
BELIMUMAB PD VIAL 400MG
|
Facility
|
IP
|
$55.83
|
|
|
Service Code
|
HCPCS J0490
|
| Hospital Charge Code |
41640279
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$27.92 |
| Max. Negotiated Rate |
$27.92 |
| Rate for Payer: Cash Price |
$52.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$27.92
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$27.92
|
|
