|
BRENTUXIMAB VEDOTIN 50MG/10ML PF
|
Facility
|
OP
|
$383.10
|
|
|
Service Code
|
HCPCS J9042
|
| Hospital Charge Code |
41648891
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$161.43 |
| Max. Negotiated Rate |
$249.02 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$210.70
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$230.61
|
| Rate for Payer: Aetna Government |
$230.61
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$161.43
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$161.43
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$161.43
|
| Rate for Payer: Brighton Health Commercial |
$229.86
|
| Rate for Payer: Cash Price |
$230.61
|
| Rate for Payer: Cash Price |
$230.61
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$230.61
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$191.55
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$220.28
|
| Rate for Payer: Elderplan Medicare Advantage |
$230.61
|
| Rate for Payer: EmblemHealth Commercial |
$230.61
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$230.61
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$230.61
|
| Rate for Payer: Fidelis Essential Plan QHP |
$242.14
|
| Rate for Payer: Fidelis Medicare Advantage |
$230.61
|
| Rate for Payer: Fidelis Qualified Health Plan |
$242.14
|
| Rate for Payer: Group Health Inc Commercial |
$230.61
|
| Rate for Payer: Group Health Inc Medicare |
$230.61
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$191.55
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$191.55
|
| Rate for Payer: Healthfirst Medicare Advantage |
$196.02
|
| Rate for Payer: Healthfirst QHP |
$230.61
|
| Rate for Payer: Humana Medicare |
$235.23
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$230.61
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$244.59
|
| Rate for Payer: SOMOS Essential |
$244.59
|
| Rate for Payer: United Healthcare Commercial |
$213.65
|
| Rate for Payer: United Healthcare Medicare Advantage |
$230.61
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$249.02
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$184.49
|
| Rate for Payer: Wellcare Medicare |
$219.08
|
|
|
BRENTUXIMAB VEDOTIN 50 MG IV SOLR [111348]
|
Facility
|
IP
|
$13,562.40
|
|
|
Service Code
|
HCPCS J9042
|
| Hospital Charge Code |
51144005001
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,781.20 |
| Max. Negotiated Rate |
$6,781.20 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$6,781.20
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$6,781.20
|
|
|
BRENTUXIMAB VEDOTIN 50 MG IV SOLR [111348]
|
Facility
|
OP
|
$13,562.40
|
|
|
Service Code
|
HCPCS J9042
|
| Hospital Charge Code |
51144005001
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$184.49 |
| Max. Negotiated Rate |
$8,815.56 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$7,459.32
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$230.61
|
| Rate for Payer: Aetna Government |
$230.61
|
| Rate for Payer: Brighton Health Commercial |
$8,137.44
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$230.61
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$6,781.20
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$7,798.38
|
| Rate for Payer: Elderplan Medicare Advantage |
$230.61
|
| Rate for Payer: EmblemHealth Commercial |
$6,781.20
|
| Rate for Payer: Fidelis Medicare Advantage |
$230.61
|
| Rate for Payer: Group Health Inc Commercial |
$230.61
|
| Rate for Payer: Group Health Inc Medicare |
$230.61
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$6,781.20
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$6,781.20
|
| Rate for Payer: Healthfirst Medicare Advantage |
$196.02
|
| Rate for Payer: Healthfirst QHP |
$230.61
|
| Rate for Payer: Humana Medicare |
$235.23
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$230.61
|
| Rate for Payer: United Healthcare Medicare Advantage |
$230.61
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$8,815.56
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$184.49
|
|
|
BRIDGE REPAIR, BY REPORT
|
Facility
|
OP
|
$496.00
|
|
|
Service Code
|
HCPCS D6980
|
| Hospital Charge Code |
42301625
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$122.12 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$272.80
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$122.12
|
| Rate for Payer: Aetna Government |
$122.12
|
| Rate for Payer: Brighton Health Commercial |
$372.00
|
| 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 |
$248.00
|
| Rate for Payer: Group Health Inc Medicare |
$173.60
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$248.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$248.00
|
|
|
BRIEF CHECK IN BY MD/QHP
|
Facility
|
OP
|
$37.83
|
|
|
Service Code
|
HCPCS G2012
|
| Hospital Charge Code |
30300132
|
|
Hospital Revenue Code
|
988
|
| Min. Negotiated Rate |
$7.89 |
| Max. Negotiated Rate |
$30.26 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$20.81
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$7.89
|
| Rate for Payer: Aetna Government |
$7.89
|
| Rate for Payer: Brighton Health Commercial |
$28.37
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$30.26
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$25.72
|
| Rate for Payer: Group Health Inc Commercial |
$18.92
|
| Rate for Payer: Group Health Inc Medicare |
$13.24
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$18.92
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$18.92
|
|
|
BRIEF CHKIN, 5-10, NON-E/M
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
HCPCS G2251
|
| Hospital Charge Code |
30300346
|
|
Hospital Revenue Code
|
929
|
| Max. Negotiated Rate |
$94.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.01
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$8.08
|
| Rate for Payer: Aetna Government |
$8.08
|
| Rate for Payer: Brighton Health Commercial |
$0.01
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.01
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.01
|
| 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 |
$0.01
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.01
|
| Rate for Payer: United Healthcare Commercial |
$94.00
|
|
|
BRIEF CHKIN BY MD/QHP, 11-20
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
HCPCS G2252
|
| Hospital Charge Code |
30300347
|
|
Hospital Revenue Code
|
929
|
| Max. Negotiated Rate |
$94.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.01
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$15.49
|
| Rate for Payer: Aetna Government |
$15.49
|
| Rate for Payer: Brighton Health Commercial |
$0.01
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.01
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.01
|
| 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 |
$0.01
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.01
|
| Rate for Payer: United Healthcare Commercial |
$94.00
|
|
|
BRIEF EMOTIONAL/BEHAV ASSMT
|
Facility
|
OP
|
$101.25
|
|
|
Service Code
|
HCPCS 96127
|
| Hospital Charge Code |
30307799
|
|
Hospital Revenue Code
|
914
|
| Min. Negotiated Rate |
$32.47 |
| Max. Negotiated Rate |
$81.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$55.69
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$46.38
|
| Rate for Payer: Aetna Government |
$46.38
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$32.47
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$32.47
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$32.47
|
| Rate for Payer: Brighton Health Commercial |
$75.94
|
| Rate for Payer: Cash Price |
$46.38
|
| Rate for Payer: Cash Price |
$46.38
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$46.38
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$81.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$68.85
|
| Rate for Payer: Elderplan Medicare Advantage |
$46.38
|
| Rate for Payer: EmblemHealth Commercial |
$46.38
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$39.42
|
| Rate for Payer: Fidelis Essential Plan QHP |
$41.28
|
| Rate for Payer: Fidelis Medicare Advantage |
$46.38
|
| Rate for Payer: Fidelis Qualified Health Plan |
$41.28
|
| Rate for Payer: Group Health Inc Commercial |
$46.38
|
| Rate for Payer: Group Health Inc Medicare |
$46.38
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$50.62
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$46.38
|
| Rate for Payer: Healthfirst Medicare Advantage |
$39.42
|
| Rate for Payer: Healthfirst QHP |
$46.38
|
| Rate for Payer: Humana Medicare |
$47.31
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$46.38
|
| Rate for Payer: United Healthcare Medicare Advantage |
$46.38
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$46.38
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$37.10
|
| Rate for Payer: Wellcare Medicare |
$44.06
|
|
|
BRIEF EMOTIONAL/BEHAV ASSMT
|
Facility
|
IP
|
$101.25
|
|
|
Service Code
|
HCPCS 96127
|
| Hospital Charge Code |
30307799
|
|
Hospital Revenue Code
|
914
|
| Rate for Payer: Cash Price |
$46.38
|
|
|
BRIEFS ADULT LARGE/1X SEAMLESS
|
Facility
|
OP
|
$1.49
|
|
| Hospital Charge Code |
64901608
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$0.52 |
| Max. Negotiated Rate |
$1.19 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.82
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.75
|
| Rate for Payer: Aetna Government |
$0.75
|
| Rate for Payer: Brighton Health Commercial |
$1.12
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.19
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.01
|
| Rate for Payer: Group Health Inc Commercial |
$0.75
|
| Rate for Payer: Group Health Inc Medicare |
$0.52
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.75
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.75
|
|
|
BRIEFS KNIT 2X/3X SEAMLESS
|
Facility
|
OP
|
$1.55
|
|
| Hospital Charge Code |
64901610
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$1.24 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.85
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.78
|
| Rate for Payer: Aetna Government |
$0.78
|
| Rate for Payer: Brighton Health Commercial |
$1.16
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.24
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.05
|
| Rate for Payer: Group Health Inc Commercial |
$0.78
|
| Rate for Payer: Group Health Inc Medicare |
$0.54
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.78
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.78
|
|
|
BRIMONIDINE 0.2% OPHTHALMIC SOLN
|
Facility
|
OP
|
$2.92
|
|
| Hospital Charge Code |
41654858
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$2.34 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.61
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.46
|
| Rate for Payer: Aetna Government |
$1.46
|
| Rate for Payer: Brighton Health Commercial |
$2.19
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2.34
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.99
|
| Rate for Payer: Group Health Inc Commercial |
$1.46
|
| Rate for Payer: Group Health Inc Medicare |
$1.02
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.46
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.46
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.90
|
|
|
BRIMONIDINE 0.2% OPHTHALMIC SOLN
|
Facility
|
OP
|
$2.92
|
|
| Hospital Charge Code |
41644858
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$2.34 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.61
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.46
|
| Rate for Payer: Aetna Government |
$1.46
|
| Rate for Payer: Brighton Health Commercial |
$2.19
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2.34
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.99
|
| Rate for Payer: Group Health Inc Commercial |
$1.46
|
| Rate for Payer: Group Health Inc Medicare |
$1.02
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.46
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.46
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.90
|
|
|
BRIMONIDINE TARTRATE 0.2 % OP SOLN [17881]
|
Facility
|
OP
|
$3.63
|
|
|
Service Code
|
NDC 24208041105
|
| Hospital Charge Code |
24208041105
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.27 |
| Max. Negotiated Rate |
$2.90 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.99
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.81
|
| Rate for Payer: Aetna Government |
$1.81
|
| Rate for Payer: Brighton Health Commercial |
$2.72
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2.90
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2.47
|
| Rate for Payer: Group Health Inc Commercial |
$1.81
|
| Rate for Payer: Group Health Inc Medicare |
$1.27
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.81
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.81
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2.36
|
|
|
BRIMONIDINE TARTRATE 0.2 % OP SOLN [17881]
|
Facility
|
OP
|
$6.52
|
|
|
Service Code
|
NDC 17478071511
|
| Hospital Charge Code |
17478071511
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.28 |
| Max. Negotiated Rate |
$5.22 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$3.59
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3.26
|
| Rate for Payer: Aetna Government |
$3.26
|
| Rate for Payer: Brighton Health Commercial |
$4.89
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$5.22
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$4.44
|
| Rate for Payer: Group Health Inc Commercial |
$3.26
|
| Rate for Payer: Group Health Inc Medicare |
$2.28
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$3.26
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$3.26
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$4.24
|
|
|
BRIMONIDINE TARTRATE 0.2 % OP SOLN [17881]
|
Facility
|
OP
|
$2.50
|
|
|
Service Code
|
NDC 70069023101
|
| Hospital Charge Code |
70069023101
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.88 |
| Max. Negotiated Rate |
$2.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.38
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.25
|
| Rate for Payer: Aetna Government |
$1.25
|
| Rate for Payer: Brighton Health Commercial |
$1.88
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.70
|
| Rate for Payer: Group Health Inc Commercial |
$1.25
|
| Rate for Payer: Group Health Inc Medicare |
$0.88
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.25
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.25
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.62
|
|
|
BRIMONIDINE TARTRATE 0.2 % OP SOLN [17881]
|
Facility
|
OP
|
$6.53
|
|
|
Service Code
|
NDC 61314014305
|
| Hospital Charge Code |
61314014305
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.29 |
| Max. Negotiated Rate |
$5.22 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$3.59
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3.26
|
| Rate for Payer: Aetna Government |
$3.26
|
| Rate for Payer: Brighton Health Commercial |
$4.90
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$5.22
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$4.44
|
| Rate for Payer: Group Health Inc Commercial |
$3.26
|
| Rate for Payer: Group Health Inc Medicare |
$2.29
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$3.26
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$3.26
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$4.24
|
|
|
BRIMONIDINE TARTRATE 0.2 % OP SOLN [17881]
|
Facility
|
OP
|
$0.75
|
|
|
Service Code
|
NDC 70069023301
|
| Hospital Charge Code |
70069023301
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$0.60 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.41
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.37
|
| Rate for Payer: Aetna Government |
$0.37
|
| Rate for Payer: Brighton Health Commercial |
$0.56
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.60
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.51
|
| Rate for Payer: Group Health Inc Commercial |
$0.37
|
| Rate for Payer: Group Health Inc Medicare |
$0.26
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.37
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.37
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.49
|
|
|
BRIMONIDINE TARTRATE 0.2 % OP SOLN [17881]
|
Facility
|
OP
|
$6.53
|
|
|
Service Code
|
NDC 61314014315
|
| Hospital Charge Code |
61314014315
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.28 |
| Max. Negotiated Rate |
$5.22 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$3.59
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3.26
|
| Rate for Payer: Aetna Government |
$3.26
|
| Rate for Payer: Brighton Health Commercial |
$4.90
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$5.22
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$4.44
|
| Rate for Payer: Group Health Inc Commercial |
$3.26
|
| Rate for Payer: Group Health Inc Medicare |
$2.28
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$3.26
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$3.26
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$4.24
|
|
|
BRIMONIDINE TARTRATE 0.2 % OP SOLN [17881]
|
Facility
|
OP
|
$6.53
|
|
|
Service Code
|
NDC 17478071510
|
| Hospital Charge Code |
17478071510
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.29 |
| Max. Negotiated Rate |
$5.22 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$3.59
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3.26
|
| Rate for Payer: Aetna Government |
$3.26
|
| Rate for Payer: Brighton Health Commercial |
$4.90
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$5.22
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$4.44
|
| Rate for Payer: Group Health Inc Commercial |
$3.26
|
| Rate for Payer: Group Health Inc Medicare |
$2.29
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$3.26
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$3.26
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$4.24
|
|
|
BRNCHSC W/THER ASPIR 1ST
|
Facility
|
IP
|
$4,332.95
|
|
|
Service Code
|
HCPCS 31645
|
| Hospital Charge Code |
30300153
|
|
Hospital Revenue Code
|
450
|
| Rate for Payer: Cash Price |
$1,962.76
|
|
|
BRNCHSC W/THER ASPIR 1ST
|
Facility
|
OP
|
$4,332.95
|
|
|
Service Code
|
HCPCS 31645
|
| Hospital Charge Code |
30300153
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$165.00 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,412.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,962.76
|
| Rate for Payer: Aetna Government |
$1,962.76
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$1,373.93
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$1,373.93
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$1,373.93
|
| Rate for Payer: Brighton Health Commercial |
$874.00
|
| Rate for Payer: Carelon Behavioral Health CHP/Medicaid |
$1,962.76
|
| Rate for Payer: Carelon Behavioral Health Medicare Advantage |
$1,962.76
|
| Rate for Payer: Cash Price |
$1,962.76
|
| Rate for Payer: Cash Price |
$1,962.76
|
| Rate for Payer: Cash Price |
$1,962.76
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,962.76
|
| 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: Elderplan Medicare Advantage |
$1,962.76
|
| Rate for Payer: EmblemHealth Commercial |
$525.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$1,668.35
|
| Rate for Payer: Fidelis Essential Plan QHP |
$1,746.86
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,962.76
|
| Rate for Payer: Fidelis Qualified Health Plan |
$1,746.86
|
| Rate for Payer: Group Health Inc Commercial |
$525.00
|
| Rate for Payer: Group Health Inc Medicare |
$525.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,166.48
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,962.76
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$165.00
|
| Rate for Payer: Healthfirst Medicare Advantage |
$225.00
|
| Rate for Payer: Healthfirst QHP |
$1,962.76
|
| Rate for Payer: Humana Medicare |
$2,002.02
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$1,962.76
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,962.76
|
| Rate for Payer: United Healthcare Commercial |
$569.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,962.76
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,962.76
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$1,570.21
|
| Rate for Payer: Wellcare Medicare |
$1,864.62
|
|
|
BROMOCRIPTINE 2.5 MG TAB
|
Facility
|
OP
|
$0.58
|
|
| Hospital Charge Code |
41651143
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.46 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.32
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.29
|
| Rate for Payer: Aetna Government |
$0.29
|
| Rate for Payer: Brighton Health Commercial |
$0.44
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.46
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.39
|
| Rate for Payer: Group Health Inc Commercial |
$0.29
|
| Rate for Payer: Group Health Inc Medicare |
$0.20
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.29
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.29
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.38
|
|
|
BROMOCRIPTINE 2.5 MG TAB
|
Facility
|
OP
|
$0.58
|
|
| Hospital Charge Code |
41641143
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.46 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.32
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.29
|
| Rate for Payer: Aetna Government |
$0.29
|
| Rate for Payer: Brighton Health Commercial |
$0.44
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.46
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.39
|
| Rate for Payer: Group Health Inc Commercial |
$0.29
|
| Rate for Payer: Group Health Inc Medicare |
$0.20
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.29
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.29
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.38
|
|
|
BROMOCRIPTINE MESYLATE 2.5 MG PO TABS [9297]
|
Facility
|
OP
|
$3.76
|
|
|
Service Code
|
NDC 00574010601
|
| Hospital Charge Code |
00574010601
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.31 |
| Max. Negotiated Rate |
$3.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2.07
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.88
|
| Rate for Payer: Aetna Government |
$1.88
|
| Rate for Payer: Brighton Health Commercial |
$2.82
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$3.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2.55
|
| Rate for Payer: Group Health Inc Commercial |
$1.88
|
| Rate for Payer: Group Health Inc Medicare |
$1.31
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.88
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.88
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2.44
|
|
