|
DIPHENOXYLATE-ATROPINE 2.5-0.025 MG PO TABS
|
Facility
|
OP
|
$0.70
|
|
|
Service Code
|
NDC 0406123601
|
| Hospital Charge Code |
0406123601
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$0.56 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.39
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.35
|
| Rate for Payer: Aetna Government |
$0.35
|
| Rate for Payer: Brighton Health Commercial |
$0.53
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.56
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.48
|
| Rate for Payer: EmblemHealth Commercial |
$0.35
|
| Rate for Payer: Group Health Inc Commercial |
$0.35
|
| Rate for Payer: Group Health Inc Medicare |
$0.25
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.35
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.35
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.46
|
|
|
DIPHENOXYLATE-ATROPINE 2.5-0.025 MG PO TABS
|
Facility
|
OP
|
$0.70
|
|
|
Service Code
|
NDC 6255949001
|
| Hospital Charge Code |
6255949001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$0.56 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.39
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.35
|
| Rate for Payer: Aetna Government |
$0.35
|
| Rate for Payer: Brighton Health Commercial |
$0.53
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.56
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.48
|
| Rate for Payer: EmblemHealth Commercial |
$0.35
|
| Rate for Payer: Group Health Inc Commercial |
$0.35
|
| Rate for Payer: Group Health Inc Medicare |
$0.25
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.35
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.35
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.46
|
|
|
DIPHTH-ACELL PERTUSSIS-TETANUS 15-23-5 LF-MCG/0.5 IM SUSP
|
Facility
|
IP
|
$69.45
|
|
|
Service Code
|
HCPCS 90700
|
| Hospital Charge Code |
4928128610
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$34.72 |
| Max. Negotiated Rate |
$34.72 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$34.72
|
|
|
DIPHTH-ACELL PERTUSSIS-TETANUS 15-23-5 LF-MCG/0.5 IM SUSP
|
Facility
|
OP
|
$69.45
|
|
|
Service Code
|
HCPCS 90700
|
| Hospital Charge Code |
4928128610
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.31 |
| Max. Negotiated Rate |
$55.56 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$38.20
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$27.70
|
| Rate for Payer: Aetna Government |
$27.70
|
| Rate for Payer: Brighton Health Commercial |
$52.08
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$55.56
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$47.22
|
| Rate for Payer: EmblemHealth Commercial |
$34.72
|
| Rate for Payer: Group Health Inc Commercial |
$34.72
|
| Rate for Payer: Group Health Inc Medicare |
$24.31
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$34.72
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$34.72
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$45.14
|
|
|
DIPHTH-ACELL PERTUSSIS-TETANUS 25-58-10 LF-MCG/0.5 IM SUSP
|
Facility
|
OP
|
$68.21
|
|
|
Service Code
|
HCPCS 90700
|
| Hospital Charge Code |
5816081052
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.87 |
| Max. Negotiated Rate |
$54.57 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$37.51
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$27.70
|
| Rate for Payer: Aetna Government |
$27.70
|
| Rate for Payer: Brighton Health Commercial |
$51.16
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$54.57
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$46.38
|
| Rate for Payer: EmblemHealth Commercial |
$34.10
|
| Rate for Payer: Group Health Inc Commercial |
$34.10
|
| Rate for Payer: Group Health Inc Medicare |
$23.87
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$34.10
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$34.10
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$44.34
|
|
|
DIPHTH-ACELL PERTUSSIS-TETANUS 25-58-10 LF-MCG/0.5 IM SUSP
|
Facility
|
IP
|
$68.21
|
|
|
Service Code
|
HCPCS 90700
|
| Hospital Charge Code |
5816081052
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$34.10 |
| Max. Negotiated Rate |
$34.10 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$34.10
|
|
|
Disorders of gallbladder & biliary tract
|
Facility
|
IP
|
$55,195.18
|
|
|
Service Code
|
APR-DRG 2843
|
| Min. Negotiated Rate |
$13,092.00 |
| Max. Negotiated Rate |
$55,195.18 |
| Rate for Payer: Affinity Essential Plan 1&2 |
$55,195.18
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$55,195.18
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$24,531.19
|
| Rate for Payer: Amida Care Medicaid |
$24,531.19
|
| Rate for Payer: EmblemHealth Essential Plan 1&2 |
$55,195.18
|
| Rate for Payer: EmblemHealth Essential Plan 3&4 |
$24,531.19
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$24,531.19
|
| Rate for Payer: Fidelis Qualified Health Plan |
$29,437.43
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$24,531.19
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$24,531.19
|
| Rate for Payer: Healthfirst Commercial |
$22,343.00
|
| Rate for Payer: Healthfirst Essential Plan |
$55,195.18
|
| Rate for Payer: Healthfirst QHP |
$13,092.00
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$24,531.19
|
| Rate for Payer: SOMOS Essential |
$55,195.18
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$55,195.18
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$55,195.18
|
| Rate for Payer: United Healthcare Medicaid |
$24,531.19
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$24,531.19
|
|
|
Disorders of gallbladder & biliary tract
|
Facility
|
IP
|
$42,175.19
|
|
|
Service Code
|
APR-DRG 2841
|
| Min. Negotiated Rate |
$6,492.00 |
| Max. Negotiated Rate |
$42,175.19 |
| Rate for Payer: Affinity Essential Plan 1&2 |
$42,175.19
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$42,175.19
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$18,744.53
|
| Rate for Payer: Amida Care Medicaid |
$18,744.53
|
| Rate for Payer: EmblemHealth Essential Plan 1&2 |
$42,175.19
|
| Rate for Payer: EmblemHealth Essential Plan 3&4 |
$18,744.53
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$18,744.53
|
| Rate for Payer: Fidelis Qualified Health Plan |
$22,493.44
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$18,744.53
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$18,744.53
|
| Rate for Payer: Healthfirst Commercial |
$11,009.00
|
| Rate for Payer: Healthfirst Essential Plan |
$42,175.19
|
| Rate for Payer: Healthfirst QHP |
$6,492.00
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$18,744.53
|
| Rate for Payer: SOMOS Essential |
$42,175.19
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$42,175.19
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$42,175.19
|
| Rate for Payer: United Healthcare Medicaid |
$18,744.53
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$18,744.53
|
|
|
Disorders of gallbladder & biliary tract
|
Facility
|
IP
|
$46,572.05
|
|
|
Service Code
|
APR-DRG 2842
|
| Min. Negotiated Rate |
$8,769.00 |
| Max. Negotiated Rate |
$46,572.05 |
| Rate for Payer: Affinity Essential Plan 1&2 |
$46,572.05
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$46,572.05
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$20,698.69
|
| Rate for Payer: Amida Care Medicaid |
$20,698.69
|
| Rate for Payer: EmblemHealth Essential Plan 1&2 |
$46,572.05
|
| Rate for Payer: EmblemHealth Essential Plan 3&4 |
$20,698.69
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$20,698.69
|
| Rate for Payer: Fidelis Qualified Health Plan |
$24,838.43
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$20,698.69
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$20,698.69
|
| Rate for Payer: Healthfirst Commercial |
$14,966.00
|
| Rate for Payer: Healthfirst Essential Plan |
$46,572.05
|
| Rate for Payer: Healthfirst QHP |
$8,769.00
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$20,698.69
|
| Rate for Payer: SOMOS Essential |
$46,572.05
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$46,572.05
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$46,572.05
|
| Rate for Payer: United Healthcare Medicaid |
$20,698.69
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$20,698.69
|
|
|
Disorders of gallbladder & biliary tract
|
Facility
|
IP
|
$84,149.41
|
|
|
Service Code
|
APR-DRG 2844
|
| Min. Negotiated Rate |
$24,933.00 |
| Max. Negotiated Rate |
$84,149.41 |
| Rate for Payer: Affinity Essential Plan 1&2 |
$84,149.41
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$84,149.41
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$37,399.74
|
| Rate for Payer: Amida Care Medicaid |
$37,399.74
|
| Rate for Payer: EmblemHealth Essential Plan 1&2 |
$84,149.41
|
| Rate for Payer: EmblemHealth Essential Plan 3&4 |
$37,399.74
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$37,399.74
|
| Rate for Payer: Fidelis Qualified Health Plan |
$44,879.69
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$37,399.74
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$37,399.74
|
| Rate for Payer: Healthfirst Commercial |
$47,926.00
|
| Rate for Payer: Healthfirst Essential Plan |
$84,149.41
|
| Rate for Payer: Healthfirst QHP |
$24,933.00
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$37,399.74
|
| Rate for Payer: SOMOS Essential |
$84,149.41
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$84,149.41
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$84,149.41
|
| Rate for Payer: United Healthcare Medicaid |
$37,399.74
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$37,399.74
|
|
|
Disorders of pancreas except malignancy
|
Facility
|
IP
|
$45,152.75
|
|
|
Service Code
|
APR-DRG 2822
|
| Min. Negotiated Rate |
$8,566.00 |
| Max. Negotiated Rate |
$45,152.75 |
| Rate for Payer: Affinity Essential Plan 1&2 |
$45,152.75
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$45,152.75
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$20,067.89
|
| Rate for Payer: Amida Care Medicaid |
$20,067.89
|
| Rate for Payer: EmblemHealth Essential Plan 1&2 |
$45,152.75
|
| Rate for Payer: EmblemHealth Essential Plan 3&4 |
$20,067.89
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$20,067.89
|
| Rate for Payer: Fidelis Qualified Health Plan |
$24,081.47
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$20,067.89
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$20,067.89
|
| Rate for Payer: Healthfirst Commercial |
$14,149.00
|
| Rate for Payer: Healthfirst Essential Plan |
$45,152.75
|
| Rate for Payer: Healthfirst QHP |
$8,566.00
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$20,067.89
|
| Rate for Payer: SOMOS Essential |
$45,152.75
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$45,152.75
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$45,152.75
|
| Rate for Payer: United Healthcare Medicaid |
$20,067.89
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$20,067.89
|
|
|
Disorders of pancreas except malignancy
|
Facility
|
IP
|
$92,813.02
|
|
|
Service Code
|
APR-DRG 2824
|
| Min. Negotiated Rate |
$34,217.00 |
| Max. Negotiated Rate |
$92,813.02 |
| Rate for Payer: Affinity Essential Plan 1&2 |
$92,813.02
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$92,813.02
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$41,250.23
|
| Rate for Payer: Amida Care Medicaid |
$41,250.23
|
| Rate for Payer: EmblemHealth Essential Plan 1&2 |
$92,813.02
|
| Rate for Payer: EmblemHealth Essential Plan 3&4 |
$41,250.23
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$41,250.23
|
| Rate for Payer: Fidelis Qualified Health Plan |
$49,500.28
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$41,250.23
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$41,250.23
|
| Rate for Payer: Healthfirst Commercial |
$63,863.00
|
| Rate for Payer: Healthfirst Essential Plan |
$92,813.02
|
| Rate for Payer: Healthfirst QHP |
$34,217.00
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$41,250.23
|
| Rate for Payer: SOMOS Essential |
$92,813.02
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$92,813.02
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$92,813.02
|
| Rate for Payer: United Healthcare Medicaid |
$41,250.23
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$41,250.23
|
|
|
Disorders of pancreas except malignancy
|
Facility
|
IP
|
$55,969.04
|
|
|
Service Code
|
APR-DRG 2823
|
| Min. Negotiated Rate |
$13,626.00 |
| Max. Negotiated Rate |
$55,969.04 |
| Rate for Payer: Affinity Essential Plan 1&2 |
$55,969.04
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$55,969.04
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$24,875.13
|
| Rate for Payer: Amida Care Medicaid |
$24,875.13
|
| Rate for Payer: EmblemHealth Essential Plan 1&2 |
$55,969.04
|
| Rate for Payer: EmblemHealth Essential Plan 3&4 |
$24,875.13
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$24,875.13
|
| Rate for Payer: Fidelis Qualified Health Plan |
$29,850.16
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$24,875.13
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$24,875.13
|
| Rate for Payer: Healthfirst Commercial |
$24,384.00
|
| Rate for Payer: Healthfirst Essential Plan |
$55,969.04
|
| Rate for Payer: Healthfirst QHP |
$13,626.00
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$24,875.13
|
| Rate for Payer: SOMOS Essential |
$55,969.04
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$55,969.04
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$55,969.04
|
| Rate for Payer: United Healthcare Medicaid |
$24,875.13
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$24,875.13
|
|
|
Disorders of pancreas except malignancy
|
Facility
|
IP
|
$41,724.94
|
|
|
Service Code
|
APR-DRG 2821
|
| Min. Negotiated Rate |
$6,920.00 |
| Max. Negotiated Rate |
$41,724.94 |
| Rate for Payer: Affinity Essential Plan 1&2 |
$41,724.94
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$41,724.94
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$18,544.42
|
| Rate for Payer: Amida Care Medicaid |
$18,544.42
|
| Rate for Payer: EmblemHealth Essential Plan 1&2 |
$41,724.94
|
| Rate for Payer: EmblemHealth Essential Plan 3&4 |
$18,544.42
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$18,544.42
|
| Rate for Payer: Fidelis Qualified Health Plan |
$22,253.30
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$18,544.42
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$18,544.42
|
| Rate for Payer: Healthfirst Commercial |
$11,427.00
|
| Rate for Payer: Healthfirst Essential Plan |
$41,724.94
|
| Rate for Payer: Healthfirst QHP |
$6,920.00
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$18,544.42
|
| Rate for Payer: SOMOS Essential |
$41,724.94
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$41,724.94
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$41,724.94
|
| Rate for Payer: United Healthcare Medicaid |
$18,544.42
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$18,544.42
|
|
|
Disorders of personality & impulse control
|
Facility
|
IP
|
$26,252.00
|
|
|
Service Code
|
APR-DRG 7522
|
| Min. Negotiated Rate |
$3,364.26 |
| Max. Negotiated Rate |
$26,252.00 |
| Rate for Payer: Affinity Essential Plan 1&2 |
$3,364.26
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$3,364.26
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$3,364.26
|
| Rate for Payer: Carelon Behavioral Health HARP/QHP |
$3,364.26
|
| Rate for Payer: EmblemHealth Essential Plan 1&2 |
$7,569.59
|
| Rate for Payer: EmblemHealth Essential Plan 3&4 |
$3,364.26
|
| Rate for Payer: Fidelis Qualified Health Plan |
$4,037.11
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$3,364.26
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$3,364.26
|
| Rate for Payer: Healthfirst Commercial |
$26,252.00
|
| Rate for Payer: Healthfirst Essential Plan |
$7,569.59
|
| Rate for Payer: Healthfirst QHP |
$6,122.95
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$3,364.26
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$7,569.59
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$7,569.59
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$3,364.26
|
| Rate for Payer: SOMOS Essential |
$7,569.59
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$7,569.59
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$7,569.59
|
| Rate for Payer: United Healthcare Medicaid |
$3,364.26
|
|
|
Disorders of personality & impulse control
|
Facility
|
IP
|
$26,252.00
|
|
|
Service Code
|
APR-DRG 7524
|
| Min. Negotiated Rate |
$3,364.26 |
| Max. Negotiated Rate |
$26,252.00 |
| Rate for Payer: Affinity Essential Plan 1&2 |
$3,364.26
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$3,364.26
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$3,364.26
|
| Rate for Payer: Carelon Behavioral Health HARP/QHP |
$3,364.26
|
| Rate for Payer: EmblemHealth Essential Plan 1&2 |
$7,569.59
|
| Rate for Payer: EmblemHealth Essential Plan 3&4 |
$3,364.26
|
| Rate for Payer: Fidelis Qualified Health Plan |
$4,037.11
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$3,364.26
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$3,364.26
|
| Rate for Payer: Healthfirst Commercial |
$26,252.00
|
| Rate for Payer: Healthfirst Essential Plan |
$7,569.59
|
| Rate for Payer: Healthfirst QHP |
$6,122.95
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$3,364.26
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$7,569.59
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$7,569.59
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$3,364.26
|
| Rate for Payer: SOMOS Essential |
$7,569.59
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$7,569.59
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$7,569.59
|
| Rate for Payer: United Healthcare Medicaid |
$3,364.26
|
|
|
Disorders of personality & impulse control
|
Facility
|
IP
|
$26,252.00
|
|
|
Service Code
|
APR-DRG 7523
|
| Min. Negotiated Rate |
$3,364.26 |
| Max. Negotiated Rate |
$26,252.00 |
| Rate for Payer: Affinity Essential Plan 1&2 |
$3,364.26
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$3,364.26
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$3,364.26
|
| Rate for Payer: Carelon Behavioral Health HARP/QHP |
$3,364.26
|
| Rate for Payer: EmblemHealth Essential Plan 1&2 |
$7,569.59
|
| Rate for Payer: EmblemHealth Essential Plan 3&4 |
$3,364.26
|
| Rate for Payer: Fidelis Qualified Health Plan |
$4,037.11
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$3,364.26
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$3,364.26
|
| Rate for Payer: Healthfirst Commercial |
$26,252.00
|
| Rate for Payer: Healthfirst Essential Plan |
$7,569.59
|
| Rate for Payer: Healthfirst QHP |
$6,122.95
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$3,364.26
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$7,569.59
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$7,569.59
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$3,364.26
|
| Rate for Payer: SOMOS Essential |
$7,569.59
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$7,569.59
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$7,569.59
|
| Rate for Payer: United Healthcare Medicaid |
$3,364.26
|
|
|
Disorders of personality & impulse control
|
Facility
|
IP
|
$26,252.00
|
|
|
Service Code
|
APR-DRG 7521
|
| Min. Negotiated Rate |
$3,323.66 |
| Max. Negotiated Rate |
$26,252.00 |
| Rate for Payer: Affinity Essential Plan 1&2 |
$3,323.66
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$3,323.66
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$3,323.66
|
| Rate for Payer: Carelon Behavioral Health HARP/QHP |
$3,323.66
|
| Rate for Payer: EmblemHealth Essential Plan 1&2 |
$7,478.23
|
| Rate for Payer: EmblemHealth Essential Plan 3&4 |
$3,323.66
|
| Rate for Payer: Fidelis Qualified Health Plan |
$3,988.39
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$3,323.66
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$3,323.66
|
| Rate for Payer: Healthfirst Commercial |
$26,252.00
|
| Rate for Payer: Healthfirst Essential Plan |
$7,478.23
|
| Rate for Payer: Healthfirst QHP |
$6,049.06
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$3,323.66
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$7,478.23
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$7,478.23
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$3,323.66
|
| Rate for Payer: SOMOS Essential |
$7,478.23
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$7,478.23
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$7,478.23
|
| Rate for Payer: United Healthcare Medicaid |
$3,323.66
|
|
|
DIVALPROEX SODIUM 125 MG PO CSDR
|
Facility
|
IP
|
$1.12
|
|
|
Service Code
|
NDC 6838210601
|
| Hospital Charge Code |
6838210601
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$0.56 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.56
|
|
|
DIVALPROEX SODIUM 125 MG PO CSDR
|
Facility
|
IP
|
$1.42
|
|
|
Service Code
|
NDC 6808431301
|
| Hospital Charge Code |
6808431301
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.71 |
| Max. Negotiated Rate |
$0.71 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.71
|
|
|
DIVALPROEX SODIUM 125 MG PO CSDR
|
Facility
|
OP
|
$1.12
|
|
|
Service Code
|
NDC 2724111501
|
| Hospital Charge Code |
2724111501
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$0.90 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.62
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.56
|
| Rate for Payer: Aetna Government |
$0.56
|
| Rate for Payer: Brighton Health Commercial |
$0.84
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.90
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.76
|
| Rate for Payer: EmblemHealth Commercial |
$0.56
|
| Rate for Payer: Group Health Inc Commercial |
$0.56
|
| Rate for Payer: Group Health Inc Medicare |
$0.39
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.56
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.56
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.73
|
|
|
DIVALPROEX SODIUM 125 MG PO CSDR
|
Facility
|
IP
|
$2.24
|
|
|
Service Code
|
NDC 0074611413
|
| Hospital Charge Code |
0074611413
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.12 |
| Max. Negotiated Rate |
$1.12 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.12
|
|
|
DIVALPROEX SODIUM 125 MG PO CSDR
|
Facility
|
OP
|
$2.24
|
|
|
Service Code
|
NDC 0074611413
|
| Hospital Charge Code |
0074611413
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.78 |
| Max. Negotiated Rate |
$1.79 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.23
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.12
|
| Rate for Payer: Aetna Government |
$1.12
|
| Rate for Payer: Brighton Health Commercial |
$1.68
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.79
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.52
|
| Rate for Payer: EmblemHealth Commercial |
$1.12
|
| Rate for Payer: Group Health Inc Commercial |
$1.12
|
| Rate for Payer: Group Health Inc Medicare |
$0.78
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.12
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.12
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.46
|
|
|
DIVALPROEX SODIUM 125 MG PO CSDR
|
Facility
|
IP
|
$1.42
|
|
|
Service Code
|
NDC 6808431311
|
| Hospital Charge Code |
6808431311
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.71 |
| Max. Negotiated Rate |
$0.71 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.71
|
|
|
DIVALPROEX SODIUM 125 MG PO CSDR
|
Facility
|
IP
|
$1.12
|
|
|
Service Code
|
NDC 5511153201
|
| Hospital Charge Code |
5511153201
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$0.56 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.56
|
|
