|
BEVACIZUMAB-MALY 100 MG/4ML IV SOLN [186421]
|
Facility
|
OP
|
$215.58
|
|
|
Service Code
|
NDC 70121175401
|
| Hospital Charge Code |
70121175401
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$75.45 |
| Max. Negotiated Rate |
$226.36 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$118.57
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$107.79
|
| Rate for Payer: Aetna Government |
$107.79
|
| Rate for Payer: Brighton Health Commercial |
$129.35
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$107.79
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$123.96
|
| Rate for Payer: EmblemHealth Commercial |
$107.79
|
| Rate for Payer: Fidelis Medicare Advantage |
$226.36
|
| Rate for Payer: Group Health Inc Commercial |
$107.79
|
| Rate for Payer: Group Health Inc Medicare |
$75.45
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$107.79
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$107.79
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$140.13
|
|
|
BEVACIZUMAB-MALY 400 MG/16ML IV SOLN [186422]
|
Facility
|
IP
|
$215.58
|
|
|
Service Code
|
NDC 70121175507
|
| Hospital Charge Code |
70121175507
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$107.79 |
| Max. Negotiated Rate |
$107.79 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$107.79
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$107.79
|
|
|
BEVACIZUMAB-MALY 400 MG/16ML IV SOLN [186422]
|
Facility
|
OP
|
$215.58
|
|
|
Service Code
|
NDC 70121175507
|
| Hospital Charge Code |
70121175507
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$75.45 |
| Max. Negotiated Rate |
$226.36 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$118.57
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$107.79
|
| Rate for Payer: Aetna Government |
$107.79
|
| Rate for Payer: Brighton Health Commercial |
$129.35
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$107.79
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$123.96
|
| Rate for Payer: EmblemHealth Commercial |
$107.79
|
| Rate for Payer: Fidelis Medicare Advantage |
$226.36
|
| Rate for Payer: Group Health Inc Commercial |
$107.79
|
| Rate for Payer: Group Health Inc Medicare |
$75.45
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$107.79
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$107.79
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$140.13
|
|
|
BEVACIZUMAB-MALY 400 MG/16ML IV SOLN [186422]
|
Facility
|
OP
|
$215.58
|
|
|
Service Code
|
NDC 70121175501
|
| Hospital Charge Code |
70121175501
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$75.45 |
| Max. Negotiated Rate |
$226.36 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$118.57
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$107.79
|
| Rate for Payer: Aetna Government |
$107.79
|
| Rate for Payer: Brighton Health Commercial |
$129.35
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$107.79
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$123.96
|
| Rate for Payer: EmblemHealth Commercial |
$107.79
|
| Rate for Payer: Fidelis Medicare Advantage |
$226.36
|
| Rate for Payer: Group Health Inc Commercial |
$107.79
|
| Rate for Payer: Group Health Inc Medicare |
$75.45
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$107.79
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$107.79
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$140.13
|
|
|
BEVACIZUMAB-MALY 400 MG/16ML IV SOLN [186422]
|
Facility
|
IP
|
$215.58
|
|
|
Service Code
|
NDC 70121175501
|
| Hospital Charge Code |
70121175501
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$107.79 |
| Max. Negotiated Rate |
$107.79 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$107.79
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$107.79
|
|
|
BEZLOTOXUMAB 1000 MG/40ML IV SOLN [137009]
|
Facility
|
OP
|
$114.00
|
|
|
Service Code
|
HCPCS J0565
|
| Hospital Charge Code |
00006302500
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$31.89 |
| Max. Negotiated Rate |
$74.10 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$62.70
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$39.86
|
| Rate for Payer: Aetna Government |
$39.86
|
| Rate for Payer: Brighton Health Commercial |
$68.40
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$39.86
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$57.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$65.55
|
| Rate for Payer: Elderplan Medicare Advantage |
$39.86
|
| Rate for Payer: EmblemHealth Commercial |
$57.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$39.86
|
| Rate for Payer: Group Health Inc Commercial |
$39.86
|
| Rate for Payer: Group Health Inc Medicare |
$39.86
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$57.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$57.00
|
| Rate for Payer: Healthfirst Medicare Advantage |
$33.88
|
| Rate for Payer: Healthfirst QHP |
$39.86
|
| Rate for Payer: Humana Medicare |
$40.66
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$39.86
|
| Rate for Payer: United Healthcare Medicare Advantage |
$39.86
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$74.10
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$31.89
|
|
|
BEZLOTOXUMAB 1000 MG/40ML IV SOLN [137009]
|
Facility
|
IP
|
$114.00
|
|
|
Service Code
|
HCPCS J0565
|
| Hospital Charge Code |
00006302500
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$57.00 |
| Max. Negotiated Rate |
$57.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$57.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$57.00
|
|
|
B-HCG QUANTITATIVE
|
Facility
|
OP
|
$37.63
|
|
|
Service Code
|
HCPCS 84702
|
| Hospital Charge Code |
40602525
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$10.54 |
| Max. Negotiated Rate |
$28.22 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$20.70
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$15.05
|
| Rate for Payer: Aetna Government |
$15.05
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$10.54
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$10.54
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$10.54
|
| Rate for Payer: Brighton Health Commercial |
$28.22
|
| Rate for Payer: Cash Price |
$15.05
|
| Rate for Payer: Cash Price |
$15.05
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$15.05
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$23.92
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$20.24
|
| Rate for Payer: Elderplan Medicare Advantage |
$15.05
|
| Rate for Payer: EmblemHealth Commercial |
$15.05
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$12.79
|
| Rate for Payer: Fidelis Essential Plan QHP |
$13.39
|
| Rate for Payer: Fidelis Medicare Advantage |
$15.05
|
| Rate for Payer: Fidelis Qualified Health Plan |
$13.39
|
| Rate for Payer: Group Health Inc Commercial |
$15.05
|
| Rate for Payer: Group Health Inc Medicare |
$15.05
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$18.82
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$15.05
|
| Rate for Payer: Healthfirst Medicare Advantage |
$15.05
|
| Rate for Payer: Healthfirst QHP |
$15.05
|
| Rate for Payer: Humana Medicare |
$15.35
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$15.05
|
| Rate for Payer: United Healthcare Commercial |
$19.07
|
| Rate for Payer: United Healthcare Medicare Advantage |
$15.05
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$15.05
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$12.04
|
| Rate for Payer: Wellcare Medicare |
$13.54
|
|
|
B-HCG QUANTITATIVE
|
Facility
|
IP
|
$37.63
|
|
|
Service Code
|
HCPCS 84702
|
| Hospital Charge Code |
40602525
|
|
Hospital Revenue Code
|
301
|
| Rate for Payer: Cash Price |
$15.05
|
|
|
B,HENSELAE AB (IGG,IGM)
|
Facility
|
IP
|
$25.45
|
|
|
Service Code
|
HCPCS 86611
|
| Hospital Charge Code |
30303373
|
|
Hospital Revenue Code
|
302
|
| Rate for Payer: Cash Price |
$10.18
|
|
|
B,HENSELAE AB (IGG,IGM)
|
Facility
|
OP
|
$25.45
|
|
|
Service Code
|
HCPCS 86611
|
| Hospital Charge Code |
30303373
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$7.13 |
| Max. Negotiated Rate |
$19.09 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$14.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$10.18
|
| Rate for Payer: Aetna Government |
$10.18
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$7.13
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$7.13
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$7.13
|
| Rate for Payer: Brighton Health Commercial |
$19.09
|
| Rate for Payer: Cash Price |
$10.18
|
| Rate for Payer: Cash Price |
$10.18
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$10.18
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$16.17
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$13.68
|
| Rate for Payer: Elderplan Medicare Advantage |
$10.18
|
| Rate for Payer: EmblemHealth Commercial |
$10.18
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$8.65
|
| Rate for Payer: Fidelis Essential Plan QHP |
$9.06
|
| Rate for Payer: Fidelis Medicare Advantage |
$10.18
|
| Rate for Payer: Fidelis Qualified Health Plan |
$9.06
|
| Rate for Payer: Group Health Inc Commercial |
$10.18
|
| Rate for Payer: Group Health Inc Medicare |
$10.18
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$12.72
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$10.18
|
| Rate for Payer: Healthfirst Medicare Advantage |
$10.18
|
| Rate for Payer: Healthfirst QHP |
$10.18
|
| Rate for Payer: Humana Medicare |
$10.38
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$10.18
|
| Rate for Payer: United Healthcare Commercial |
$12.89
|
| Rate for Payer: United Healthcare Medicare Advantage |
$10.18
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$10.18
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$8.14
|
| Rate for Payer: Wellcare Medicare |
$9.16
|
|
|
BICALUTAMIDE 50 MG PO TABS [15746]
|
Facility
|
OP
|
$18.25
|
|
|
Service Code
|
NDC 62559089030
|
| Hospital Charge Code |
62559089030
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.39 |
| Max. Negotiated Rate |
$14.60 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$10.04
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$9.13
|
| Rate for Payer: Aetna Government |
$9.13
|
| Rate for Payer: Brighton Health Commercial |
$13.69
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$14.60
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$12.41
|
| Rate for Payer: Group Health Inc Commercial |
$9.13
|
| Rate for Payer: Group Health Inc Medicare |
$6.39
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$9.13
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$9.13
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$11.86
|
|
|
BICALUTAMIDE 50 MG PO TABS [15746]
|
Facility
|
OP
|
$18.53
|
|
|
Service Code
|
NDC 47335048583
|
| Hospital Charge Code |
47335048583
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.49 |
| Max. Negotiated Rate |
$14.83 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$10.19
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$9.27
|
| Rate for Payer: Aetna Government |
$9.27
|
| Rate for Payer: Brighton Health Commercial |
$13.90
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$14.83
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$12.60
|
| Rate for Payer: Group Health Inc Commercial |
$9.27
|
| Rate for Payer: Group Health Inc Medicare |
$6.49
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$9.27
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$9.27
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$12.05
|
|
|
BICALUTAMIDE 50 MG PO TABS [15746]
|
Facility
|
OP
|
$18.35
|
|
|
Service Code
|
NDC 16729002301
|
| Hospital Charge Code |
16729002301
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.42 |
| Max. Negotiated Rate |
$14.68 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$10.09
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$9.18
|
| Rate for Payer: Aetna Government |
$9.18
|
| Rate for Payer: Brighton Health Commercial |
$13.77
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$14.68
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$12.48
|
| Rate for Payer: Group Health Inc Commercial |
$9.18
|
| Rate for Payer: Group Health Inc Medicare |
$6.42
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$9.18
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$9.18
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$11.93
|
|
|
BICALUTAMIDE 50 MG TAB
|
Facility
|
OP
|
$2.10
|
|
| Hospital Charge Code |
41652629
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.74 |
| Max. Negotiated Rate |
$1.68 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.16
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.05
|
| Rate for Payer: Aetna Government |
$1.05
|
| Rate for Payer: Brighton Health Commercial |
$1.58
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.68
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.43
|
| Rate for Payer: Group Health Inc Commercial |
$1.05
|
| Rate for Payer: Group Health Inc Medicare |
$0.74
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.05
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.05
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.36
|
|
|
BICALUTAMIDE 50 MG TAB
|
Facility
|
OP
|
$2.10
|
|
| Hospital Charge Code |
41642629
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.74 |
| Max. Negotiated Rate |
$1.68 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.16
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.05
|
| Rate for Payer: Aetna Government |
$1.05
|
| Rate for Payer: Brighton Health Commercial |
$1.58
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.68
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.43
|
| Rate for Payer: Group Health Inc Commercial |
$1.05
|
| Rate for Payer: Group Health Inc Medicare |
$0.74
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.05
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.05
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.36
|
|
|
BICARBONATE STERILYTE
|
Facility
|
OP
|
$9.81
|
|
| Hospital Charge Code |
64902072
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$3.43 |
| Max. Negotiated Rate |
$7.85 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$5.40
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$4.90
|
| Rate for Payer: Aetna Government |
$4.90
|
| Rate for Payer: Brighton Health Commercial |
$7.36
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$7.85
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$6.67
|
| Rate for Payer: Group Health Inc Commercial |
$4.90
|
| Rate for Payer: Group Health Inc Medicare |
$3.43
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4.90
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4.90
|
|
|
BICILLIN CR 900-300MU
|
Facility
|
OP
|
$0.17
|
|
|
Service Code
|
HCPCS J0558
|
| Hospital Charge Code |
41644790
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$18.46 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.09
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$17.58
|
| Rate for Payer: Aetna Government |
$17.58
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$12.30
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$12.30
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$12.30
|
| Rate for Payer: Brighton Health Commercial |
$0.10
|
| Rate for Payer: Cash Price |
$17.58
|
| Rate for Payer: Cash Price |
$17.58
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$17.58
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.09
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.10
|
| Rate for Payer: Elderplan Medicare Advantage |
$17.58
|
| Rate for Payer: EmblemHealth Commercial |
$17.58
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$17.58
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$17.58
|
| Rate for Payer: Fidelis Essential Plan QHP |
$18.46
|
| Rate for Payer: Fidelis Medicare Advantage |
$17.58
|
| Rate for Payer: Fidelis Qualified Health Plan |
$18.46
|
| Rate for Payer: Group Health Inc Commercial |
$17.58
|
| Rate for Payer: Group Health Inc Medicare |
$17.58
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.09
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.09
|
| Rate for Payer: Healthfirst Medicare Advantage |
$14.94
|
| Rate for Payer: Healthfirst QHP |
$17.58
|
| Rate for Payer: Humana Medicare |
$17.93
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$17.58
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$18.41
|
| Rate for Payer: SOMOS Essential |
$18.41
|
| Rate for Payer: United Healthcare Commercial |
$13.88
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.58
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.11
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$14.06
|
| Rate for Payer: Wellcare Medicare |
$16.70
|
|
|
BICILLIN CR 900-300MU
|
Facility
|
IP
|
$0.17
|
|
|
Service Code
|
HCPCS J0558
|
| Hospital Charge Code |
41654790
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Cash Price |
$17.58
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.09
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.09
|
|
|
BICILLIN CR 900-300MU
|
Facility
|
IP
|
$0.17
|
|
|
Service Code
|
HCPCS J0558
|
| Hospital Charge Code |
41644790
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Cash Price |
$17.58
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.09
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.09
|
|
|
BICILLIN CR 900-300MU
|
Facility
|
OP
|
$0.17
|
|
|
Service Code
|
HCPCS J0558
|
| Hospital Charge Code |
41654790
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$18.46 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.09
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$17.58
|
| Rate for Payer: Aetna Government |
$17.58
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$12.30
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$12.30
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$12.30
|
| Rate for Payer: Brighton Health Commercial |
$0.10
|
| Rate for Payer: Cash Price |
$17.58
|
| Rate for Payer: Cash Price |
$17.58
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$17.58
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.09
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.10
|
| Rate for Payer: Elderplan Medicare Advantage |
$17.58
|
| Rate for Payer: EmblemHealth Commercial |
$17.58
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$17.58
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$17.58
|
| Rate for Payer: Fidelis Essential Plan QHP |
$18.46
|
| Rate for Payer: Fidelis Medicare Advantage |
$17.58
|
| Rate for Payer: Fidelis Qualified Health Plan |
$18.46
|
| Rate for Payer: Group Health Inc Commercial |
$17.58
|
| Rate for Payer: Group Health Inc Medicare |
$17.58
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.09
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.09
|
| Rate for Payer: Healthfirst Medicare Advantage |
$14.94
|
| Rate for Payer: Healthfirst QHP |
$17.58
|
| Rate for Payer: Humana Medicare |
$17.93
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$17.58
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$18.41
|
| Rate for Payer: SOMOS Essential |
$18.41
|
| Rate for Payer: United Healthcare Commercial |
$13.88
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.58
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.11
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$14.06
|
| Rate for Payer: Wellcare Medicare |
$16.70
|
|
|
BICTEGRAVIR/EMTRICITABINE/TENOFOV
|
Facility
|
OP
|
$245.23
|
|
| Hospital Charge Code |
41658888
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$85.83 |
| Max. Negotiated Rate |
$196.18 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$134.88
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$122.62
|
| Rate for Payer: Aetna Government |
$122.62
|
| Rate for Payer: Brighton Health Commercial |
$183.92
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$196.18
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$166.76
|
| Rate for Payer: Group Health Inc Commercial |
$122.62
|
| Rate for Payer: Group Health Inc Medicare |
$85.83
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$122.62
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$122.62
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$159.40
|
|
|
BICTEGRAVIR/EMTRICITABINE/TENOFOV
|
Facility
|
OP
|
$245.23
|
|
| Hospital Charge Code |
41648888
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$85.83 |
| Max. Negotiated Rate |
$196.18 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$134.88
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$122.62
|
| Rate for Payer: Aetna Government |
$122.62
|
| Rate for Payer: Brighton Health Commercial |
$183.92
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$196.18
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$166.76
|
| Rate for Payer: Group Health Inc Commercial |
$122.62
|
| Rate for Payer: Group Health Inc Medicare |
$85.83
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$122.62
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$122.62
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$159.40
|
|
|
BICTEGRAVIR-EMTRICITAB-TENOFOV 50-200-25 MG PO TABS [151328]
|
Facility
|
OP
|
$159.25
|
|
|
Service Code
|
NDC 61958250103
|
| Hospital Charge Code |
61958250103
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$55.74 |
| Max. Negotiated Rate |
$127.40 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$87.59
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$79.62
|
| Rate for Payer: Aetna Government |
$79.62
|
| Rate for Payer: Brighton Health Commercial |
$119.44
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$127.40
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$108.29
|
| Rate for Payer: Group Health Inc Commercial |
$79.62
|
| Rate for Payer: Group Health Inc Medicare |
$55.74
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$79.62
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$79.62
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$103.51
|
|
|
BICTEGRAVIR-EMTRICITAB-TENOFOV 50-200-25 MG PO TABS [151328]
|
Facility
|
OP
|
$159.25
|
|
|
Service Code
|
NDC 61958250101
|
| Hospital Charge Code |
61958250101
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$55.74 |
| Max. Negotiated Rate |
$127.40 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$87.59
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$79.62
|
| Rate for Payer: Aetna Government |
$79.62
|
| Rate for Payer: Brighton Health Commercial |
$119.44
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$127.40
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$108.29
|
| Rate for Payer: Group Health Inc Commercial |
$79.62
|
| Rate for Payer: Group Health Inc Medicare |
$55.74
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$79.62
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$79.62
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$103.51
|
|
