|
BETAXOLOL 0.5% OPHTHALMIC SOLN
|
Facility
|
OP
|
$101.94
|
|
| Hospital Charge Code |
41642664
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$35.68 |
| Max. Negotiated Rate |
$81.55 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$56.07
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$50.97
|
| Rate for Payer: Aetna Government |
$50.97
|
| Rate for Payer: Brighton Health Commercial |
$76.46
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$81.55
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$69.32
|
| Rate for Payer: Group Health Inc Commercial |
$50.97
|
| Rate for Payer: Group Health Inc Medicare |
$35.68
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$50.97
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$50.97
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$66.26
|
|
|
BETAXOLOL 0.5% OPHTHALMIC SOLN
|
Facility
|
OP
|
$101.94
|
|
| Hospital Charge Code |
41652664
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$35.68 |
| Max. Negotiated Rate |
$81.55 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$56.07
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$50.97
|
| Rate for Payer: Aetna Government |
$50.97
|
| Rate for Payer: Brighton Health Commercial |
$76.46
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$81.55
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$69.32
|
| Rate for Payer: Group Health Inc Commercial |
$50.97
|
| Rate for Payer: Group Health Inc Medicare |
$35.68
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$50.97
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$50.97
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$66.26
|
|
|
BETAXOLOL HCL 0.5 % OP SOLN [9268]
|
Facility
|
OP
|
$13.25
|
|
|
Service Code
|
NDC 61314024501
|
| Hospital Charge Code |
61314024501
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.64 |
| Max. Negotiated Rate |
$10.60 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$7.29
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$6.63
|
| Rate for Payer: Aetna Government |
$6.63
|
| Rate for Payer: Brighton Health Commercial |
$9.94
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$10.60
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$9.01
|
| Rate for Payer: Group Health Inc Commercial |
$6.63
|
| Rate for Payer: Group Health Inc Medicare |
$4.64
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$6.63
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$6.63
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$8.62
|
|
|
BETHANECHOL 25 MG TAB
|
Facility
|
OP
|
$0.53
|
|
| Hospital Charge Code |
41653572
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.42 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.29
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.27
|
| Rate for Payer: Aetna Government |
$0.27
|
| Rate for Payer: Brighton Health Commercial |
$0.40
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.42
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.36
|
| Rate for Payer: Group Health Inc Commercial |
$0.27
|
| Rate for Payer: Group Health Inc Medicare |
$0.19
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.27
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.27
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.34
|
|
|
BETHANECHOL 25 MG TAB
|
Facility
|
OP
|
$0.53
|
|
| Hospital Charge Code |
41643572
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.42 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.29
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.27
|
| Rate for Payer: Aetna Government |
$0.27
|
| Rate for Payer: Brighton Health Commercial |
$0.40
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.42
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.36
|
| Rate for Payer: Group Health Inc Commercial |
$0.27
|
| Rate for Payer: Group Health Inc Medicare |
$0.19
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.27
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.27
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.34
|
|
|
BETHANECHOL 5 MG TAB
|
Facility
|
OP
|
$1.00
|
|
| Hospital Charge Code |
41643451
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$0.80 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.55
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.50
|
| Rate for Payer: Aetna Government |
$0.50
|
| Rate for Payer: Brighton Health Commercial |
$0.75
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.80
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.68
|
| 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: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.65
|
|
|
BETHANECHOL 5 MG TAB
|
Facility
|
OP
|
$1.00
|
|
| Hospital Charge Code |
41653451
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$0.80 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.55
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.50
|
| Rate for Payer: Aetna Government |
$0.50
|
| Rate for Payer: Brighton Health Commercial |
$0.75
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.80
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.68
|
| 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: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.65
|
|
|
BETHANECHOL CHLORIDE 25 MG PO TABS [1044]
|
Facility
|
OP
|
$2.67
|
|
|
Service Code
|
NDC 00832051289
|
| Hospital Charge Code |
00832051289
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.93 |
| Max. Negotiated Rate |
$2.14 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.47
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.34
|
| Rate for Payer: Aetna Government |
$1.34
|
| Rate for Payer: Brighton Health Commercial |
$2.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2.14
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.82
|
| Rate for Payer: Group Health Inc Commercial |
$1.34
|
| Rate for Payer: Group Health Inc Medicare |
$0.93
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.34
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.34
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.74
|
|
|
BETHANECHOL CHLORIDE 5 MG PO TABS [1045]
|
Facility
|
OP
|
$0.90
|
|
|
Service Code
|
NDC 00832051000
|
| Hospital Charge Code |
00832051000
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$0.72 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.45
|
| Rate for Payer: Aetna Government |
$0.45
|
| Rate for Payer: Brighton Health Commercial |
$0.68
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.72
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.61
|
| Rate for Payer: Group Health Inc Commercial |
$0.45
|
| Rate for Payer: Group Health Inc Medicare |
$0.32
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.45
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.45
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.59
|
|
|
BEVACIZUMAB 100 MG/4 ML INJ
|
Facility
|
OP
|
$199.22
|
|
|
Service Code
|
HCPCS J9035
|
| Hospital Charge Code |
41643654
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$51.85 |
| Max. Negotiated Rate |
$129.49 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$109.57
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$74.07
|
| Rate for Payer: Aetna Government |
$74.07
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$51.85
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$51.85
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$51.85
|
| Rate for Payer: Brighton Health Commercial |
$119.53
|
| Rate for Payer: Cash Price |
$74.07
|
| Rate for Payer: Cash Price |
$74.07
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$74.07
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$99.61
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$114.55
|
| Rate for Payer: Elderplan Medicare Advantage |
$74.07
|
| Rate for Payer: EmblemHealth Commercial |
$74.07
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$74.07
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$74.07
|
| Rate for Payer: Fidelis Essential Plan QHP |
$77.78
|
| Rate for Payer: Fidelis Medicare Advantage |
$74.07
|
| Rate for Payer: Fidelis Qualified Health Plan |
$77.78
|
| Rate for Payer: Group Health Inc Commercial |
$74.07
|
| Rate for Payer: Group Health Inc Medicare |
$74.07
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$99.61
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$99.61
|
| Rate for Payer: Healthfirst Medicare Advantage |
$62.96
|
| Rate for Payer: Healthfirst QHP |
$74.07
|
| Rate for Payer: Humana Medicare |
$75.55
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$74.07
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$78.61
|
| Rate for Payer: SOMOS Essential |
$78.61
|
| Rate for Payer: United Healthcare Commercial |
$70.75
|
| Rate for Payer: United Healthcare Medicare Advantage |
$74.07
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$129.49
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$59.26
|
| Rate for Payer: Wellcare Medicare |
$70.37
|
|
|
BEVACIZUMAB 100 MG/4 ML INJ
|
Facility
|
IP
|
$199.22
|
|
|
Service Code
|
HCPCS J9035
|
| Hospital Charge Code |
41653654
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$99.61 |
| Max. Negotiated Rate |
$99.61 |
| Rate for Payer: Cash Price |
$74.07
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$99.61
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$99.61
|
|
|
BEVACIZUMAB 100 MG/4 ML INJ
|
Facility
|
IP
|
$199.22
|
|
|
Service Code
|
HCPCS J9035
|
| Hospital Charge Code |
41643654
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$99.61 |
| Max. Negotiated Rate |
$99.61 |
| Rate for Payer: Cash Price |
$74.07
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$99.61
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$99.61
|
|
|
BEVACIZUMAB 100 MG/4 ML INJ
|
Facility
|
OP
|
$199.22
|
|
|
Service Code
|
HCPCS J9035
|
| Hospital Charge Code |
41653654
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$51.85 |
| Max. Negotiated Rate |
$129.49 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$109.57
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$74.07
|
| Rate for Payer: Aetna Government |
$74.07
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$51.85
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$51.85
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$51.85
|
| Rate for Payer: Brighton Health Commercial |
$119.53
|
| Rate for Payer: Cash Price |
$74.07
|
| Rate for Payer: Cash Price |
$74.07
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$74.07
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$99.61
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$114.55
|
| Rate for Payer: Elderplan Medicare Advantage |
$74.07
|
| Rate for Payer: EmblemHealth Commercial |
$74.07
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$74.07
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$74.07
|
| Rate for Payer: Fidelis Essential Plan QHP |
$77.78
|
| Rate for Payer: Fidelis Medicare Advantage |
$74.07
|
| Rate for Payer: Fidelis Qualified Health Plan |
$77.78
|
| Rate for Payer: Group Health Inc Commercial |
$74.07
|
| Rate for Payer: Group Health Inc Medicare |
$74.07
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$99.61
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$99.61
|
| Rate for Payer: Healthfirst Medicare Advantage |
$62.96
|
| Rate for Payer: Healthfirst QHP |
$74.07
|
| Rate for Payer: Humana Medicare |
$75.55
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$74.07
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$78.61
|
| Rate for Payer: SOMOS Essential |
$78.61
|
| Rate for Payer: United Healthcare Commercial |
$70.75
|
| Rate for Payer: United Healthcare Medicare Advantage |
$74.07
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$129.49
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$59.26
|
| Rate for Payer: Wellcare Medicare |
$70.37
|
|
|
BEVACIZUMAB 100 MG/4ML IV SOLN [108065]
|
Facility
|
OP
|
$239.08
|
|
|
Service Code
|
HCPCS J9035
|
| Hospital Charge Code |
50242006001
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$59.26 |
| Max. Negotiated Rate |
$155.40 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$131.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$74.07
|
| Rate for Payer: Aetna Government |
$74.07
|
| Rate for Payer: Brighton Health Commercial |
$143.45
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$74.07
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$119.54
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$137.47
|
| Rate for Payer: Elderplan Medicare Advantage |
$74.07
|
| Rate for Payer: EmblemHealth Commercial |
$119.54
|
| Rate for Payer: Fidelis Medicare Advantage |
$74.07
|
| Rate for Payer: Group Health Inc Commercial |
$74.07
|
| Rate for Payer: Group Health Inc Medicare |
$74.07
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$119.54
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$119.54
|
| Rate for Payer: Healthfirst Medicare Advantage |
$62.96
|
| Rate for Payer: Healthfirst QHP |
$74.07
|
| Rate for Payer: Humana Medicare |
$75.55
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$74.07
|
| Rate for Payer: United Healthcare Medicare Advantage |
$74.07
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$155.40
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$59.26
|
|
|
BEVACIZUMAB 100 MG/4ML IV SOLN [108065]
|
Facility
|
IP
|
$239.08
|
|
|
Service Code
|
HCPCS J9035
|
| Hospital Charge Code |
50242006001
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$119.54 |
| Max. Negotiated Rate |
$119.54 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$119.54
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$119.54
|
|
|
BEVACIZUMAB 3 MG/0.12ML IZ SOSY [177593]
|
Facility
|
OP
|
$239.08
|
|
|
Service Code
|
HCPCS J9035
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$51.85 |
| Max. Negotiated Rate |
$191.27 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$131.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$74.07
|
| Rate for Payer: Aetna Government |
$74.07
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$51.85
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$51.85
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$51.85
|
| Rate for Payer: Brighton Health Commercial |
$179.31
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$74.07
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$191.27
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$162.58
|
| Rate for Payer: Elderplan Medicare Advantage |
$74.07
|
| Rate for Payer: EmblemHealth Commercial |
$74.07
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$62.96
|
| Rate for Payer: Fidelis Essential Plan QHP |
$65.92
|
| Rate for Payer: Fidelis Medicare Advantage |
$74.07
|
| Rate for Payer: Fidelis Qualified Health Plan |
$65.92
|
| Rate for Payer: Group Health Inc Commercial |
$74.07
|
| Rate for Payer: Group Health Inc Medicare |
$74.07
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$119.54
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$74.07
|
| Rate for Payer: Healthfirst Medicare Advantage |
$62.96
|
| Rate for Payer: Healthfirst QHP |
$74.07
|
| Rate for Payer: Humana Medicare |
$75.55
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$74.16
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$78.61
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$78.61
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$78.61
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$74.07
|
| Rate for Payer: United Healthcare Medicare Advantage |
$74.07
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$155.40
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$59.26
|
| Rate for Payer: Wellcare Medicare |
$70.37
|
|
|
BEVACIZUMAB 3 MG/0.12ML IZ SOSY [177593]
|
Facility
|
OP
|
$1,508.00
|
|
|
Service Code
|
HCPCS J9035
|
| Hospital Charge Code |
71266800601
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$51.85 |
| Max. Negotiated Rate |
$1,206.40 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$829.40
|
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$131.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$74.07
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$74.07
|
| Rate for Payer: Aetna Government |
$74.07
|
| Rate for Payer: Aetna Government |
$74.07
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$51.85
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$51.85
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$51.85
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$51.85
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$51.85
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$51.85
|
| Rate for Payer: Brighton Health Commercial |
$179.31
|
| Rate for Payer: Brighton Health Commercial |
$1,131.00
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$74.07
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$74.07
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,206.40
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$191.27
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$162.58
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,025.44
|
| Rate for Payer: Elderplan Medicare Advantage |
$74.07
|
| Rate for Payer: Elderplan Medicare Advantage |
$74.07
|
| Rate for Payer: EmblemHealth Commercial |
$74.07
|
| Rate for Payer: EmblemHealth Commercial |
$74.07
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$62.96
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$62.96
|
| Rate for Payer: Fidelis Essential Plan QHP |
$65.92
|
| Rate for Payer: Fidelis Essential Plan QHP |
$65.92
|
| Rate for Payer: Fidelis Medicare Advantage |
$74.07
|
| Rate for Payer: Fidelis Medicare Advantage |
$74.07
|
| Rate for Payer: Fidelis Qualified Health Plan |
$65.92
|
| Rate for Payer: Fidelis Qualified Health Plan |
$65.92
|
| Rate for Payer: Group Health Inc Commercial |
$74.07
|
| Rate for Payer: Group Health Inc Commercial |
$74.07
|
| Rate for Payer: Group Health Inc Medicare |
$74.07
|
| Rate for Payer: Group Health Inc Medicare |
$74.07
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$119.54
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$754.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$74.07
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$74.07
|
| Rate for Payer: Healthfirst Medicare Advantage |
$62.96
|
| Rate for Payer: Healthfirst Medicare Advantage |
$62.96
|
| Rate for Payer: Healthfirst QHP |
$74.07
|
| Rate for Payer: Healthfirst QHP |
$74.07
|
| Rate for Payer: Humana Medicare |
$75.55
|
| Rate for Payer: Humana Medicare |
$75.55
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$74.16
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$74.16
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$78.61
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$78.61
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$78.61
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$78.61
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$78.61
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$78.61
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$74.07
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$74.07
|
| Rate for Payer: United Healthcare Medicare Advantage |
$74.07
|
| Rate for Payer: United Healthcare Medicare Advantage |
$74.07
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$155.40
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$980.20
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$59.26
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$59.26
|
| Rate for Payer: Wellcare Medicare |
$70.37
|
| Rate for Payer: Wellcare Medicare |
$70.37
|
|
|
BEVACIZUMAB 400 MG/16 ML INJ
|
Facility
|
OP
|
$226.00
|
|
|
Service Code
|
HCPCS J9035
|
| Hospital Charge Code |
41653846
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$51.85 |
| Max. Negotiated Rate |
$146.90 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$124.30
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$74.07
|
| Rate for Payer: Aetna Government |
$74.07
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$51.85
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$51.85
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$51.85
|
| Rate for Payer: Brighton Health Commercial |
$135.60
|
| Rate for Payer: Cash Price |
$74.07
|
| Rate for Payer: Cash Price |
$74.07
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$74.07
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$113.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$129.95
|
| Rate for Payer: Elderplan Medicare Advantage |
$74.07
|
| Rate for Payer: EmblemHealth Commercial |
$74.07
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$74.07
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$74.07
|
| Rate for Payer: Fidelis Essential Plan QHP |
$77.78
|
| Rate for Payer: Fidelis Medicare Advantage |
$74.07
|
| Rate for Payer: Fidelis Qualified Health Plan |
$77.78
|
| Rate for Payer: Group Health Inc Commercial |
$74.07
|
| Rate for Payer: Group Health Inc Medicare |
$74.07
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$113.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$113.00
|
| Rate for Payer: Healthfirst Medicare Advantage |
$62.96
|
| Rate for Payer: Healthfirst QHP |
$74.07
|
| Rate for Payer: Humana Medicare |
$75.55
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$74.07
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$78.61
|
| Rate for Payer: SOMOS Essential |
$78.61
|
| Rate for Payer: United Healthcare Commercial |
$70.75
|
| Rate for Payer: United Healthcare Medicare Advantage |
$74.07
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$146.90
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$59.26
|
| Rate for Payer: Wellcare Medicare |
$70.37
|
|
|
BEVACIZUMAB 400 MG/16 ML INJ
|
Facility
|
IP
|
$226.00
|
|
|
Service Code
|
HCPCS J9035
|
| Hospital Charge Code |
41643846
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$113.00 |
| Max. Negotiated Rate |
$113.00 |
| Rate for Payer: Cash Price |
$74.07
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$113.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$113.00
|
|
|
BEVACIZUMAB 400 MG/16 ML INJ
|
Facility
|
OP
|
$226.00
|
|
|
Service Code
|
HCPCS J9035
|
| Hospital Charge Code |
41643846
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$51.85 |
| Max. Negotiated Rate |
$146.90 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$124.30
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$74.07
|
| Rate for Payer: Aetna Government |
$74.07
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$51.85
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$51.85
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$51.85
|
| Rate for Payer: Brighton Health Commercial |
$135.60
|
| Rate for Payer: Cash Price |
$74.07
|
| Rate for Payer: Cash Price |
$74.07
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$74.07
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$113.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$129.95
|
| Rate for Payer: Elderplan Medicare Advantage |
$74.07
|
| Rate for Payer: EmblemHealth Commercial |
$74.07
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$74.07
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$74.07
|
| Rate for Payer: Fidelis Essential Plan QHP |
$77.78
|
| Rate for Payer: Fidelis Medicare Advantage |
$74.07
|
| Rate for Payer: Fidelis Qualified Health Plan |
$77.78
|
| Rate for Payer: Group Health Inc Commercial |
$74.07
|
| Rate for Payer: Group Health Inc Medicare |
$74.07
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$113.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$113.00
|
| Rate for Payer: Healthfirst Medicare Advantage |
$62.96
|
| Rate for Payer: Healthfirst QHP |
$74.07
|
| Rate for Payer: Humana Medicare |
$75.55
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$74.07
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$78.61
|
| Rate for Payer: SOMOS Essential |
$78.61
|
| Rate for Payer: United Healthcare Commercial |
$70.75
|
| Rate for Payer: United Healthcare Medicare Advantage |
$74.07
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$146.90
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$59.26
|
| Rate for Payer: Wellcare Medicare |
$70.37
|
|
|
BEVACIZUMAB 400 MG/16 ML INJ
|
Facility
|
IP
|
$226.00
|
|
|
Service Code
|
HCPCS J9035
|
| Hospital Charge Code |
41653846
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$113.00 |
| Max. Negotiated Rate |
$113.00 |
| Rate for Payer: Cash Price |
$74.07
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$113.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$113.00
|
|
|
BEVACIZUMAB 400 MG/16ML IV SOLN [108066]
|
Facility
|
IP
|
$239.08
|
|
|
Service Code
|
HCPCS J9035
|
| Hospital Charge Code |
50242006101
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$119.54 |
| Max. Negotiated Rate |
$119.54 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$119.54
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$119.54
|
|
|
BEVACIZUMAB 400 MG/16ML IV SOLN [108066]
|
Facility
|
OP
|
$239.08
|
|
|
Service Code
|
HCPCS J9035
|
| Hospital Charge Code |
50242006101
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$59.26 |
| Max. Negotiated Rate |
$155.40 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$131.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$74.07
|
| Rate for Payer: Aetna Government |
$74.07
|
| Rate for Payer: Brighton Health Commercial |
$143.45
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$74.07
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$119.54
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$137.47
|
| Rate for Payer: Elderplan Medicare Advantage |
$74.07
|
| Rate for Payer: EmblemHealth Commercial |
$119.54
|
| Rate for Payer: Fidelis Medicare Advantage |
$74.07
|
| Rate for Payer: Group Health Inc Commercial |
$74.07
|
| Rate for Payer: Group Health Inc Medicare |
$74.07
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$119.54
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$119.54
|
| Rate for Payer: Healthfirst Medicare Advantage |
$62.96
|
| Rate for Payer: Healthfirst QHP |
$74.07
|
| Rate for Payer: Humana Medicare |
$75.55
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$74.07
|
| Rate for Payer: United Healthcare Medicare Advantage |
$74.07
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$155.40
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$59.26
|
|
|
BEVACIZUMAB-AWWB 100 MG/4ML IV SOLN [168888]
|
Facility
|
IP
|
$209.32
|
|
|
Service Code
|
HCPCS Q5107
|
| Hospital Charge Code |
55513020601
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$104.66 |
| Max. Negotiated Rate |
$104.66 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$104.66
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$104.66
|
|
|
BEVACIZUMAB-AWWB 100 MG/4ML IV SOLN [168888]
|
Facility
|
OP
|
$209.32
|
|
|
Service Code
|
HCPCS Q5107
|
| Hospital Charge Code |
55513020601
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$20.50 |
| Max. Negotiated Rate |
$136.06 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$115.13
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$25.62
|
| Rate for Payer: Aetna Government |
$25.62
|
| Rate for Payer: Brighton Health Commercial |
$125.59
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$25.62
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$104.66
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$120.36
|
| Rate for Payer: Elderplan Medicare Advantage |
$25.62
|
| Rate for Payer: EmblemHealth Commercial |
$104.66
|
| Rate for Payer: Fidelis Medicare Advantage |
$25.62
|
| Rate for Payer: Group Health Inc Commercial |
$25.62
|
| Rate for Payer: Group Health Inc Medicare |
$25.62
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$104.66
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$104.66
|
| Rate for Payer: Healthfirst Medicare Advantage |
$21.78
|
| Rate for Payer: Healthfirst QHP |
$25.62
|
| Rate for Payer: Humana Medicare |
$26.13
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$25.62
|
| Rate for Payer: United Healthcare Medicare Advantage |
$25.62
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$136.06
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$20.50
|
|
