|
BX PLT 4H .4MM 10MMX10MM
|
Facility
|
OP
|
$558.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
40205298
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$134.20 |
| Max. Negotiated Rate |
$585.90 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$306.90
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$134.20
|
| Rate for Payer: Aetna Government |
$134.20
|
| Rate for Payer: Brighton Health Commercial |
$334.80
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$279.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$320.85
|
| Rate for Payer: EmblemHealth Commercial |
$279.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$585.90
|
| Rate for Payer: Group Health Inc Commercial |
$279.00
|
| Rate for Payer: Group Health Inc Medicare |
$195.30
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$279.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$279.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$362.70
|
|
|
BX PLT 4H .4MM 10MMX10MM
|
Facility
|
IP
|
$558.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
40205298
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$279.00 |
| Max. Negotiated Rate |
$279.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$279.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$279.00
|
|
|
BX VAG MUCOSA, EXTENSIVE
|
Facility
|
IP
|
$7,566.13
|
|
|
Service Code
|
HCPCS 57105
|
| Hospital Charge Code |
30301267
|
|
Hospital Revenue Code
|
510
|
| Rate for Payer: Cash Price |
$3,615.39
|
|
|
BX VAG MUCOSA, EXTENSIVE
|
Facility
|
OP
|
$7,566.13
|
|
|
Service Code
|
HCPCS 57105
|
| Hospital Charge Code |
30301267
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$222.00 |
| Max. Negotiated Rate |
$3,783.06 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,888.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3,615.39
|
| Rate for Payer: Aetna Government |
$3,615.39
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$2,530.77
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$2,530.77
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$2,530.77
|
| Rate for Payer: Brighton Health Commercial |
$233.00
|
| Rate for Payer: Cash Price |
$3,615.39
|
| Rate for Payer: Cash Price |
$3,615.39
|
| Rate for Payer: Cash Price |
$3,615.39
|
| Rate for Payer: Cash Price |
$3,615.39
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$3,615.39
|
| 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 |
$3,615.39
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$3,073.08
|
| Rate for Payer: Fidelis Essential Plan QHP |
$3,217.70
|
| Rate for Payer: Fidelis Medicare Advantage |
$3,615.39
|
| Rate for Payer: Fidelis Qualified Health Plan |
$3,217.70
|
| Rate for Payer: Group Health Inc Commercial |
$250.00
|
| Rate for Payer: Group Health Inc Medicare |
$250.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$3,783.06
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$3,615.39
|
| Rate for Payer: Healthfirst Medicare Advantage |
$3,073.08
|
| Rate for Payer: Healthfirst QHP |
$3,615.39
|
| Rate for Payer: Humana Medicare |
$3,687.70
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$3,615.39
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$3,615.39
|
| Rate for Payer: United Healthcare Commercial |
$222.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,615.39
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3,615.39
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$2,892.31
|
| Rate for Payer: Wellcare Medicare |
$3,434.62
|
|
|
BX VULVA OR PERINEUM EA ADDLESION
|
Facility
|
OP
|
$106.40
|
|
|
Service Code
|
HCPCS 56606
|
| Hospital Charge Code |
42201728
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$37.21 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$342.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$37.21
|
| Rate for Payer: Aetna Government |
$37.21
|
| Rate for Payer: Brighton Health Commercial |
$233.00
|
| 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 |
$250.00
|
| Rate for Payer: Group Health Inc Medicare |
$250.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$53.20
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$53.20
|
| Rate for Payer: United Healthcare Commercial |
$222.00
|
|
|
BYPASS GRAFT AORTO-RENAL
|
Facility
|
OP
|
$5,350.60
|
|
|
Service Code
|
HCPCS 35560
|
| Hospital Charge Code |
40039874
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,496.00 |
| Max. Negotiated Rate |
$4,012.95 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,942.83
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,957.39
|
| Rate for Payer: Aetna Government |
$1,957.39
|
| Rate for Payer: Brighton Health Commercial |
$4,012.95
|
| 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: EmblemHealth Commercial |
$1,505.00
|
| Rate for Payer: Group Health Inc Commercial |
$2,675.30
|
| Rate for Payer: Group Health Inc Medicare |
$1,872.71
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,675.30
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2,675.30
|
| Rate for Payer: United Healthcare Commercial |
$1,496.00
|
|
|
BYPASS GRAFT ILIO-ILIAC
|
Facility
|
OP
|
$4,086.70
|
|
|
Service Code
|
HCPCS 35563
|
| Hospital Charge Code |
40039875
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,430.34 |
| Max. Negotiated Rate |
$3,065.02 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,247.68
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,514.46
|
| Rate for Payer: Aetna Government |
$1,514.46
|
| Rate for Payer: Brighton Health Commercial |
$3,065.02
|
| 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: EmblemHealth Commercial |
$1,505.00
|
| Rate for Payer: Group Health Inc Commercial |
$2,043.35
|
| Rate for Payer: Group Health Inc Medicare |
$1,430.34
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,043.35
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2,043.35
|
| Rate for Payer: United Healthcare Commercial |
$1,496.00
|
|
|
C001-IGE PENICILLIN G
|
Facility
|
OP
|
$13.05
|
|
|
Service Code
|
HCPCS 86003
|
| Hospital Charge Code |
40729306
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$3.65 |
| Max. Negotiated Rate |
$9.79 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$7.18
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$5.22
|
| Rate for Payer: Aetna Government |
$5.22
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$3.65
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$3.65
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$3.65
|
| Rate for Payer: Brighton Health Commercial |
$9.79
|
| Rate for Payer: Cash Price |
$5.22
|
| Rate for Payer: Cash Price |
$5.22
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$5.22
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$8.28
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$7.01
|
| Rate for Payer: Elderplan Medicare Advantage |
$5.22
|
| Rate for Payer: EmblemHealth Commercial |
$5.22
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$4.44
|
| Rate for Payer: Fidelis Essential Plan QHP |
$4.65
|
| Rate for Payer: Fidelis Medicare Advantage |
$5.22
|
| Rate for Payer: Fidelis Qualified Health Plan |
$4.65
|
| Rate for Payer: Group Health Inc Commercial |
$5.22
|
| Rate for Payer: Group Health Inc Medicare |
$5.22
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$6.52
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$5.22
|
| Rate for Payer: Healthfirst Medicare Advantage |
$5.22
|
| Rate for Payer: Healthfirst QHP |
$5.22
|
| Rate for Payer: Humana Medicare |
$5.32
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$5.22
|
| Rate for Payer: United Healthcare Commercial |
$6.61
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5.22
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$5.22
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$4.18
|
| Rate for Payer: Wellcare Medicare |
$4.70
|
|
|
C001-IGE PENICILLIN G
|
Facility
|
IP
|
$13.05
|
|
|
Service Code
|
HCPCS 86003
|
| Hospital Charge Code |
40729306
|
|
Hospital Revenue Code
|
300
|
| Rate for Payer: Cash Price |
$5.22
|
|
|
C002-IGE PENICILLIN V
|
Facility
|
OP
|
$13.05
|
|
|
Service Code
|
HCPCS 86003
|
| Hospital Charge Code |
40729307
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$3.65 |
| Max. Negotiated Rate |
$9.79 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$7.18
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$5.22
|
| Rate for Payer: Aetna Government |
$5.22
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$3.65
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$3.65
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$3.65
|
| Rate for Payer: Brighton Health Commercial |
$9.79
|
| Rate for Payer: Cash Price |
$5.22
|
| Rate for Payer: Cash Price |
$5.22
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$5.22
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$8.28
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$7.01
|
| Rate for Payer: Elderplan Medicare Advantage |
$5.22
|
| Rate for Payer: EmblemHealth Commercial |
$5.22
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$4.44
|
| Rate for Payer: Fidelis Essential Plan QHP |
$4.65
|
| Rate for Payer: Fidelis Medicare Advantage |
$5.22
|
| Rate for Payer: Fidelis Qualified Health Plan |
$4.65
|
| Rate for Payer: Group Health Inc Commercial |
$5.22
|
| Rate for Payer: Group Health Inc Medicare |
$5.22
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$6.52
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$5.22
|
| Rate for Payer: Healthfirst Medicare Advantage |
$5.22
|
| Rate for Payer: Healthfirst QHP |
$5.22
|
| Rate for Payer: Humana Medicare |
$5.32
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$5.22
|
| Rate for Payer: United Healthcare Commercial |
$6.61
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5.22
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$5.22
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$4.18
|
| Rate for Payer: Wellcare Medicare |
$4.70
|
|
|
C002-IGE PENICILLIN V
|
Facility
|
IP
|
$13.05
|
|
|
Service Code
|
HCPCS 86003
|
| Hospital Charge Code |
40729307
|
|
Hospital Revenue Code
|
300
|
| Rate for Payer: Cash Price |
$5.22
|
|
|
C006-IGE AMOXICILLOYL
|
Facility
|
OP
|
$13.05
|
|
|
Service Code
|
HCPCS 86003
|
| Hospital Charge Code |
40729771
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$3.65 |
| Max. Negotiated Rate |
$9.79 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$7.18
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$5.22
|
| Rate for Payer: Aetna Government |
$5.22
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$3.65
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$3.65
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$3.65
|
| Rate for Payer: Brighton Health Commercial |
$9.79
|
| Rate for Payer: Cash Price |
$5.22
|
| Rate for Payer: Cash Price |
$5.22
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$5.22
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$8.28
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$7.01
|
| Rate for Payer: Elderplan Medicare Advantage |
$5.22
|
| Rate for Payer: EmblemHealth Commercial |
$5.22
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$4.44
|
| Rate for Payer: Fidelis Essential Plan QHP |
$4.65
|
| Rate for Payer: Fidelis Medicare Advantage |
$5.22
|
| Rate for Payer: Fidelis Qualified Health Plan |
$4.65
|
| Rate for Payer: Group Health Inc Commercial |
$5.22
|
| Rate for Payer: Group Health Inc Medicare |
$5.22
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$6.52
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$5.22
|
| Rate for Payer: Healthfirst Medicare Advantage |
$5.22
|
| Rate for Payer: Healthfirst QHP |
$5.22
|
| Rate for Payer: Humana Medicare |
$5.32
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$5.22
|
| Rate for Payer: United Healthcare Commercial |
$6.61
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5.22
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$5.22
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$4.18
|
| Rate for Payer: Wellcare Medicare |
$4.70
|
|
|
C006-IGE AMOXICILLOYL
|
Facility
|
IP
|
$13.05
|
|
|
Service Code
|
HCPCS 86003
|
| Hospital Charge Code |
40729771
|
|
Hospital Revenue Code
|
305
|
| Rate for Payer: Cash Price |
$5.22
|
|
|
C1 ESTERASE INHIBITOR, SERUM
|
Facility
|
IP
|
$30.00
|
|
|
Service Code
|
HCPCS 86160
|
| Hospital Charge Code |
40609138
|
|
Hospital Revenue Code
|
300
|
| Rate for Payer: Cash Price |
$12.00
|
|
|
C1 ESTERASE INHIBITOR, SERUM
|
Facility
|
OP
|
$30.00
|
|
|
Service Code
|
HCPCS 86160
|
| Hospital Charge Code |
40609138
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.40 |
| Max. Negotiated Rate |
$22.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$16.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$12.00
|
| Rate for Payer: Aetna Government |
$12.00
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$8.40
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$8.40
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$8.40
|
| Rate for Payer: Brighton Health Commercial |
$22.50
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$12.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$19.08
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$16.15
|
| Rate for Payer: Elderplan Medicare Advantage |
$12.00
|
| Rate for Payer: EmblemHealth Commercial |
$12.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$10.20
|
| Rate for Payer: Fidelis Essential Plan QHP |
$10.68
|
| Rate for Payer: Fidelis Medicare Advantage |
$12.00
|
| Rate for Payer: Fidelis Qualified Health Plan |
$10.68
|
| Rate for Payer: Group Health Inc Commercial |
$12.00
|
| Rate for Payer: Group Health Inc Medicare |
$12.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$15.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$12.00
|
| Rate for Payer: Healthfirst Medicare Advantage |
$12.00
|
| Rate for Payer: Healthfirst QHP |
$12.00
|
| Rate for Payer: Humana Medicare |
$12.24
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$12.00
|
| Rate for Payer: United Healthcare Commercial |
$15.20
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$12.00
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$9.60
|
| Rate for Payer: Wellcare Medicare |
$10.80
|
|
|
C203-IGE AMPICILLIN
|
Facility
|
IP
|
$13.05
|
|
|
Service Code
|
HCPCS 86003
|
| Hospital Charge Code |
40729837
|
|
Hospital Revenue Code
|
305
|
| Rate for Payer: Cash Price |
$5.22
|
|
|
C203-IGE AMPICILLIN
|
Facility
|
OP
|
$13.05
|
|
|
Service Code
|
HCPCS 86003
|
| Hospital Charge Code |
40729837
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$3.65 |
| Max. Negotiated Rate |
$9.79 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$7.18
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$5.22
|
| Rate for Payer: Aetna Government |
$5.22
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$3.65
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$3.65
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$3.65
|
| Rate for Payer: Brighton Health Commercial |
$9.79
|
| Rate for Payer: Cash Price |
$5.22
|
| Rate for Payer: Cash Price |
$5.22
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$5.22
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$8.28
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$7.01
|
| Rate for Payer: Elderplan Medicare Advantage |
$5.22
|
| Rate for Payer: EmblemHealth Commercial |
$5.22
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$4.44
|
| Rate for Payer: Fidelis Essential Plan QHP |
$4.65
|
| Rate for Payer: Fidelis Medicare Advantage |
$5.22
|
| Rate for Payer: Fidelis Qualified Health Plan |
$4.65
|
| Rate for Payer: Group Health Inc Commercial |
$5.22
|
| Rate for Payer: Group Health Inc Medicare |
$5.22
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$6.52
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$5.22
|
| Rate for Payer: Healthfirst Medicare Advantage |
$5.22
|
| Rate for Payer: Healthfirst QHP |
$5.22
|
| Rate for Payer: Humana Medicare |
$5.32
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$5.22
|
| Rate for Payer: United Healthcare Commercial |
$6.61
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5.22
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$5.22
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$4.18
|
| Rate for Payer: Wellcare Medicare |
$4.70
|
|
|
CA_19-9
|
Facility
|
OP
|
$52.03
|
|
|
Service Code
|
HCPCS 86301
|
| Hospital Charge Code |
40609142
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$14.57 |
| Max. Negotiated Rate |
$39.02 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$28.62
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$20.81
|
| Rate for Payer: Aetna Government |
$20.81
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$14.57
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$14.57
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$14.57
|
| Rate for Payer: Brighton Health Commercial |
$39.02
|
| Rate for Payer: Cash Price |
$20.81
|
| Rate for Payer: Cash Price |
$20.81
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$20.81
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$33.08
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$28.00
|
| Rate for Payer: Elderplan Medicare Advantage |
$20.81
|
| Rate for Payer: EmblemHealth Commercial |
$20.81
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$17.69
|
| Rate for Payer: Fidelis Essential Plan QHP |
$18.52
|
| Rate for Payer: Fidelis Medicare Advantage |
$20.81
|
| Rate for Payer: Fidelis Qualified Health Plan |
$18.52
|
| Rate for Payer: Group Health Inc Commercial |
$20.81
|
| Rate for Payer: Group Health Inc Medicare |
$20.81
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$26.02
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$20.81
|
| Rate for Payer: Healthfirst Medicare Advantage |
$20.81
|
| Rate for Payer: Healthfirst QHP |
$20.81
|
| Rate for Payer: Humana Medicare |
$21.23
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$20.81
|
| Rate for Payer: United Healthcare Commercial |
$26.36
|
| Rate for Payer: United Healthcare Medicare Advantage |
$20.81
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$20.81
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$16.65
|
| Rate for Payer: Wellcare Medicare |
$18.73
|
|
|
CA_19-9
|
Facility
|
IP
|
$52.03
|
|
|
Service Code
|
HCPCS 86301
|
| Hospital Charge Code |
40609142
|
|
Hospital Revenue Code
|
300
|
| Rate for Payer: Cash Price |
$20.81
|
|
|
CA_27.29
|
Facility
|
OP
|
$52.03
|
|
|
Service Code
|
HCPCS 86300
|
| Hospital Charge Code |
40609745
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$14.57 |
| Max. Negotiated Rate |
$39.02 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$28.62
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$20.81
|
| Rate for Payer: Aetna Government |
$20.81
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$14.57
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$14.57
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$14.57
|
| Rate for Payer: Brighton Health Commercial |
$39.02
|
| Rate for Payer: Cash Price |
$20.81
|
| Rate for Payer: Cash Price |
$20.81
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$20.81
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$33.08
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$28.00
|
| Rate for Payer: Elderplan Medicare Advantage |
$20.81
|
| Rate for Payer: EmblemHealth Commercial |
$20.81
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$17.69
|
| Rate for Payer: Fidelis Essential Plan QHP |
$18.52
|
| Rate for Payer: Fidelis Medicare Advantage |
$20.81
|
| Rate for Payer: Fidelis Qualified Health Plan |
$18.52
|
| Rate for Payer: Group Health Inc Commercial |
$20.81
|
| Rate for Payer: Group Health Inc Medicare |
$20.81
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$26.02
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$20.81
|
| Rate for Payer: Healthfirst Medicare Advantage |
$20.81
|
| Rate for Payer: Healthfirst QHP |
$20.81
|
| Rate for Payer: Humana Medicare |
$21.23
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$20.81
|
| Rate for Payer: United Healthcare Commercial |
$26.36
|
| Rate for Payer: United Healthcare Medicare Advantage |
$20.81
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$20.81
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$16.65
|
| Rate for Payer: Wellcare Medicare |
$18.73
|
|
|
CA_27.29
|
Facility
|
IP
|
$52.03
|
|
|
Service Code
|
HCPCS 86300
|
| Hospital Charge Code |
40609745
|
|
Hospital Revenue Code
|
302
|
| Rate for Payer: Cash Price |
$20.81
|
|
|
CABAZITAXEL 60MG/1.5ML INJ
|
Facility
|
IP
|
$482.00
|
|
|
Service Code
|
HCPCS J9043
|
| Hospital Charge Code |
41656050
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$241.00 |
| Max. Negotiated Rate |
$241.00 |
| Rate for Payer: Cash Price |
$210.45
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$241.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$241.00
|
|
|
CABAZITAXEL 60MG/1.5ML INJ
|
Facility
|
OP
|
$482.00
|
|
|
Service Code
|
HCPCS J9043
|
| Hospital Charge Code |
41656050
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$147.32 |
| Max. Negotiated Rate |
$313.30 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$265.10
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$210.45
|
| Rate for Payer: Aetna Government |
$210.45
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$147.32
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$147.32
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$147.32
|
| Rate for Payer: Brighton Health Commercial |
$289.20
|
| Rate for Payer: Cash Price |
$210.45
|
| Rate for Payer: Cash Price |
$210.45
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$210.45
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$241.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$277.15
|
| Rate for Payer: Elderplan Medicare Advantage |
$210.45
|
| Rate for Payer: EmblemHealth Commercial |
$210.45
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$210.45
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$210.45
|
| Rate for Payer: Fidelis Essential Plan QHP |
$220.98
|
| Rate for Payer: Fidelis Medicare Advantage |
$210.45
|
| Rate for Payer: Fidelis Qualified Health Plan |
$220.98
|
| Rate for Payer: Group Health Inc Commercial |
$210.45
|
| Rate for Payer: Group Health Inc Medicare |
$210.45
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$241.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$241.00
|
| Rate for Payer: Healthfirst Medicare Advantage |
$178.89
|
| Rate for Payer: Healthfirst QHP |
$210.45
|
| Rate for Payer: Humana Medicare |
$214.66
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$210.45
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$224.46
|
| Rate for Payer: SOMOS Essential |
$224.46
|
| Rate for Payer: United Healthcare Commercial |
$199.21
|
| Rate for Payer: United Healthcare Medicare Advantage |
$210.45
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$313.30
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$168.36
|
| Rate for Payer: Wellcare Medicare |
$199.93
|
|
|
CABAZITAXEL 60MG/1.5ML INJ
|
Facility
|
IP
|
$482.00
|
|
|
Service Code
|
HCPCS J9043
|
| Hospital Charge Code |
41646050
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$241.00 |
| Max. Negotiated Rate |
$241.00 |
| Rate for Payer: Cash Price |
$210.45
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$241.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$241.00
|
|
|
CABAZITAXEL 60MG/1.5ML INJ
|
Facility
|
OP
|
$482.00
|
|
|
Service Code
|
HCPCS J9043
|
| Hospital Charge Code |
41646050
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$147.32 |
| Max. Negotiated Rate |
$313.30 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$265.10
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$210.45
|
| Rate for Payer: Aetna Government |
$210.45
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$147.32
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$147.32
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$147.32
|
| Rate for Payer: Brighton Health Commercial |
$289.20
|
| Rate for Payer: Cash Price |
$210.45
|
| Rate for Payer: Cash Price |
$210.45
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$210.45
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$241.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$277.15
|
| Rate for Payer: Elderplan Medicare Advantage |
$210.45
|
| Rate for Payer: EmblemHealth Commercial |
$210.45
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$210.45
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$210.45
|
| Rate for Payer: Fidelis Essential Plan QHP |
$220.98
|
| Rate for Payer: Fidelis Medicare Advantage |
$210.45
|
| Rate for Payer: Fidelis Qualified Health Plan |
$220.98
|
| Rate for Payer: Group Health Inc Commercial |
$210.45
|
| Rate for Payer: Group Health Inc Medicare |
$210.45
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$241.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$241.00
|
| Rate for Payer: Healthfirst Medicare Advantage |
$178.89
|
| Rate for Payer: Healthfirst QHP |
$210.45
|
| Rate for Payer: Humana Medicare |
$214.66
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$210.45
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$224.46
|
| Rate for Payer: SOMOS Essential |
$224.46
|
| Rate for Payer: United Healthcare Commercial |
$199.21
|
| Rate for Payer: United Healthcare Medicare Advantage |
$210.45
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$313.30
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$168.36
|
| Rate for Payer: Wellcare Medicare |
$199.93
|
|
