|
CLOTRIMAZOLE 1% VAGINAL CREAM 45 GRAMS
|
Facility
|
OP
|
$5.00
|
|
| Hospital Charge Code |
41640717
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.75 |
| Max. Negotiated Rate |
$4.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2.75
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.50
|
| Rate for Payer: Aetna Government |
$2.50
|
| Rate for Payer: Brighton Health Commercial |
$3.75
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$4.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$3.40
|
| Rate for Payer: Group Health Inc Commercial |
$2.50
|
| Rate for Payer: Group Health Inc Medicare |
$1.75
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3.25
|
|
|
CLOZAPINE 100 MG PO TABS [9647]
|
Facility
|
OP
|
$3.42
|
|
|
Service Code
|
NDC 16729014201
|
| Hospital Charge Code |
16729014201
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.20 |
| Max. Negotiated Rate |
$2.74 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.88
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.71
|
| Rate for Payer: Aetna Government |
$1.71
|
| Rate for Payer: Brighton Health Commercial |
$2.56
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2.74
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2.32
|
| Rate for Payer: Group Health Inc Commercial |
$1.71
|
| Rate for Payer: Group Health Inc Medicare |
$1.20
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.71
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.71
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2.22
|
|
|
CLOZAPINE 100 MG PO TABS [9647]
|
Facility
|
OP
|
$1.12
|
|
|
Service Code
|
NDC 00904708761
|
| Hospital Charge Code |
00904708761
|
|
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: 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
|
|
|
CLOZAPINE 100 MG PO TABS [9647]
|
Facility
|
OP
|
$2.06
|
|
|
Service Code
|
NDC 51862090205
|
| Hospital Charge Code |
51862090205
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.72 |
| Max. Negotiated Rate |
$1.65 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.13
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.03
|
| Rate for Payer: Aetna Government |
$1.03
|
| Rate for Payer: Brighton Health Commercial |
$1.55
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.65
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.40
|
| Rate for Payer: Group Health Inc Commercial |
$1.03
|
| Rate for Payer: Group Health Inc Medicare |
$0.72
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.03
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.03
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.34
|
|
|
CLOZAPINE 100 MG TAB
|
Facility
|
OP
|
$1.93
|
|
| Hospital Charge Code |
41653772
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.68 |
| Max. Negotiated Rate |
$1.54 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.06
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.97
|
| Rate for Payer: Aetna Government |
$0.97
|
| Rate for Payer: Brighton Health Commercial |
$1.45
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.54
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.31
|
| Rate for Payer: Group Health Inc Commercial |
$0.97
|
| Rate for Payer: Group Health Inc Medicare |
$0.68
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.97
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.97
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.25
|
|
|
CLOZAPINE 100 MG TAB
|
Facility
|
OP
|
$1.93
|
|
| Hospital Charge Code |
41643772
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.68 |
| Max. Negotiated Rate |
$1.54 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.06
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.97
|
| Rate for Payer: Aetna Government |
$0.97
|
| Rate for Payer: Brighton Health Commercial |
$1.45
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.54
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.31
|
| Rate for Payer: Group Health Inc Commercial |
$0.97
|
| Rate for Payer: Group Health Inc Medicare |
$0.68
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.97
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.97
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.25
|
|
|
CLOZAPINE 25 MG PO TABS [9648]
|
Facility
|
OP
|
$7.32
|
|
|
Service Code
|
NDC 69809012605
|
| Hospital Charge Code |
69809012605
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.56 |
| Max. Negotiated Rate |
$5.86 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$4.03
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3.66
|
| Rate for Payer: Aetna Government |
$3.66
|
| Rate for Payer: Brighton Health Commercial |
$5.49
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$5.86
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$4.98
|
| Rate for Payer: Group Health Inc Commercial |
$3.66
|
| Rate for Payer: Group Health Inc Medicare |
$2.56
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$3.66
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$3.66
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$4.76
|
|
|
CLOZAPINE 25 MG PO TABS [9648]
|
Facility
|
OP
|
$1.33
|
|
|
Service Code
|
NDC 60687040401
|
| Hospital Charge Code |
60687040401
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.47 |
| Max. Negotiated Rate |
$1.06 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.73
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.67
|
| Rate for Payer: Aetna Government |
$0.67
|
| Rate for Payer: Brighton Health Commercial |
$1.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.06
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.90
|
| Rate for Payer: Group Health Inc Commercial |
$0.67
|
| Rate for Payer: Group Health Inc Medicare |
$0.47
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.67
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.67
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.86
|
|
|
CLOZAPINE 25 MG PO TABS [9648]
|
Facility
|
OP
|
$0.43
|
|
|
Service Code
|
NDC 00904708961
|
| Hospital Charge Code |
00904708961
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.34 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.24
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.22
|
| Rate for Payer: Aetna Government |
$0.22
|
| Rate for Payer: Brighton Health Commercial |
$0.32
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.34
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.29
|
| Rate for Payer: Group Health Inc Commercial |
$0.22
|
| Rate for Payer: Group Health Inc Medicare |
$0.15
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.22
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.22
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.28
|
|
|
CLOZAPINE 25 MG TAB
|
Facility
|
IP
|
$0.76
|
|
|
Service Code
|
HCPCS S0136
|
| Hospital Charge Code |
41643771
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$0.38 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.38
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.38
|
|
|
CLOZAPINE 25 MG TAB
|
Facility
|
OP
|
$0.76
|
|
|
Service Code
|
HCPCS S0136
|
| Hospital Charge Code |
41653771
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$0.62 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.42
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.62
|
| Rate for Payer: Aetna Government |
$0.62
|
| Rate for Payer: Brighton Health Commercial |
$0.46
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.38
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.44
|
| Rate for Payer: Group Health Inc Commercial |
$0.38
|
| Rate for Payer: Group Health Inc Medicare |
$0.27
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.38
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.38
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.49
|
|
|
CLOZAPINE 25 MG TAB
|
Facility
|
IP
|
$0.76
|
|
|
Service Code
|
HCPCS S0136
|
| Hospital Charge Code |
41653771
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$0.38 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.38
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.38
|
|
|
CLOZAPINE 25 MG TAB
|
Facility
|
OP
|
$0.76
|
|
|
Service Code
|
HCPCS S0136
|
| Hospital Charge Code |
41643771
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$0.62 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.42
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.62
|
| Rate for Payer: Aetna Government |
$0.62
|
| Rate for Payer: Brighton Health Commercial |
$0.46
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.38
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.44
|
| Rate for Payer: Group Health Inc Commercial |
$0.38
|
| Rate for Payer: Group Health Inc Medicare |
$0.27
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.38
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.38
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.49
|
|
|
CLOZAPINE (CLOZARIL), SERUM
|
Facility
|
OP
|
$50.38
|
|
|
Service Code
|
HCPCS 80159
|
| Hospital Charge Code |
40609002
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$14.10 |
| Max. Negotiated Rate |
$40.30 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$27.71
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$20.15
|
| Rate for Payer: Aetna Government |
$20.15
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$14.10
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$14.10
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$14.10
|
| Rate for Payer: Brighton Health Commercial |
$37.78
|
| Rate for Payer: Cash Price |
$20.15
|
| Rate for Payer: Cash Price |
$20.15
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$20.15
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$40.30
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$34.26
|
| Rate for Payer: Elderplan Medicare Advantage |
$20.15
|
| Rate for Payer: EmblemHealth Commercial |
$20.15
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$17.13
|
| Rate for Payer: Fidelis Essential Plan QHP |
$17.93
|
| Rate for Payer: Fidelis Medicare Advantage |
$20.15
|
| Rate for Payer: Fidelis Qualified Health Plan |
$17.93
|
| Rate for Payer: Group Health Inc Commercial |
$20.15
|
| Rate for Payer: Group Health Inc Medicare |
$20.15
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$25.19
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$20.15
|
| Rate for Payer: Healthfirst Medicare Advantage |
$20.15
|
| Rate for Payer: Healthfirst QHP |
$20.15
|
| Rate for Payer: Humana Medicare |
$20.55
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$20.15
|
| Rate for Payer: United Healthcare Commercial |
$22.71
|
| Rate for Payer: United Healthcare Medicare Advantage |
$20.15
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$20.15
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$16.12
|
| Rate for Payer: Wellcare Medicare |
$18.14
|
|
|
CLOZAPINE (CLOZARIL), SERUM
|
Facility
|
IP
|
$50.38
|
|
|
Service Code
|
HCPCS 80159
|
| Hospital Charge Code |
40609002
|
|
Hospital Revenue Code
|
300
|
| Rate for Payer: Cash Price |
$20.15
|
|
|
CLOZAPINE ODT 100MG TABLET
|
Facility
|
OP
|
$20.44
|
|
| Hospital Charge Code |
41650308
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.15 |
| Max. Negotiated Rate |
$16.35 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$11.24
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$10.22
|
| Rate for Payer: Aetna Government |
$10.22
|
| Rate for Payer: Brighton Health Commercial |
$15.33
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$16.35
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$13.90
|
| Rate for Payer: Group Health Inc Commercial |
$10.22
|
| Rate for Payer: Group Health Inc Medicare |
$7.15
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$10.22
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$10.22
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$13.29
|
|
|
CLOZAPINE ODT 100MG TABLET
|
Facility
|
OP
|
$20.44
|
|
| Hospital Charge Code |
41640308
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.15 |
| Max. Negotiated Rate |
$16.35 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$11.24
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$10.22
|
| Rate for Payer: Aetna Government |
$10.22
|
| Rate for Payer: Brighton Health Commercial |
$15.33
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$16.35
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$13.90
|
| Rate for Payer: Group Health Inc Commercial |
$10.22
|
| Rate for Payer: Group Health Inc Medicare |
$7.15
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$10.22
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$10.22
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$13.29
|
|
|
CLOZAPINE ODT 25MG TABLET
|
Facility
|
OP
|
$7.49
|
|
| Hospital Charge Code |
41650310
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.62 |
| Max. Negotiated Rate |
$5.99 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$4.12
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3.74
|
| Rate for Payer: Aetna Government |
$3.74
|
| Rate for Payer: Brighton Health Commercial |
$5.62
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$5.99
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$5.09
|
| Rate for Payer: Group Health Inc Commercial |
$3.74
|
| Rate for Payer: Group Health Inc Medicare |
$2.62
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$3.74
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$3.74
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$4.87
|
|
|
CLOZAPINE ODT 25MG TABLET
|
Facility
|
OP
|
$7.49
|
|
| Hospital Charge Code |
41640310
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.62 |
| Max. Negotiated Rate |
$5.99 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$4.12
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3.74
|
| Rate for Payer: Aetna Government |
$3.74
|
| Rate for Payer: Brighton Health Commercial |
$5.62
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$5.99
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$5.09
|
| Rate for Payer: Group Health Inc Commercial |
$3.74
|
| Rate for Payer: Group Health Inc Medicare |
$2.62
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$3.74
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$3.74
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$4.87
|
|
|
CL REDUCTION MAXIL FX
|
Facility
|
OP
|
$7,933.18
|
|
|
Service Code
|
HCPCS 21421
|
| Hospital Charge Code |
30105300
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$165.00 |
| Max. Negotiated Rate |
$3,966.59 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,485.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3,723.23
|
| Rate for Payer: Aetna Government |
$3,723.23
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$2,606.26
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$2,606.26
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$2,606.26
|
| Rate for Payer: Brighton Health Commercial |
$874.00
|
| Rate for Payer: Carelon Behavioral Health CHP/Medicaid |
$3,723.23
|
| Rate for Payer: Carelon Behavioral Health Medicare Advantage |
$3,723.23
|
| Rate for Payer: Cash Price |
$3,723.23
|
| Rate for Payer: Cash Price |
$3,723.23
|
| Rate for Payer: Cash Price |
$3,723.23
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$3,723.23
|
| 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 |
$3,723.23
|
| Rate for Payer: EmblemHealth Commercial |
$525.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$3,164.75
|
| Rate for Payer: Fidelis Essential Plan QHP |
$3,313.67
|
| Rate for Payer: Fidelis Medicare Advantage |
$3,723.23
|
| Rate for Payer: Fidelis Qualified Health Plan |
$3,313.67
|
| 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 |
$3,966.59
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$3,723.23
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$165.00
|
| Rate for Payer: Healthfirst Medicare Advantage |
$225.00
|
| Rate for Payer: Healthfirst QHP |
$3,723.23
|
| Rate for Payer: Humana Medicare |
$3,797.69
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$3,723.23
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$3,723.23
|
| Rate for Payer: United Healthcare Commercial |
$569.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,723.23
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3,723.23
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$2,978.58
|
| Rate for Payer: Wellcare Medicare |
$3,537.07
|
|
|
CL REDUCTION MAXIL FX
|
Facility
|
IP
|
$7,933.18
|
|
|
Service Code
|
HCPCS 21421
|
| Hospital Charge Code |
30105300
|
|
Hospital Revenue Code
|
450
|
| Rate for Payer: Cash Price |
$3,723.23
|
|
|
CLSD TRMENT SHOULDER DISLOCATION
|
Facility
|
IP
|
$653.13
|
|
|
Service Code
|
HCPCS 23650
|
| Hospital Charge Code |
30306668
|
|
Hospital Revenue Code
|
510
|
| Rate for Payer: Cash Price |
$272.71
|
|
|
CLSD TRMENT SHOULDER DISLOCATION
|
Facility
|
OP
|
$653.13
|
|
|
Service Code
|
HCPCS 23650
|
| Hospital Charge Code |
30306668
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$190.90 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,412.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$272.71
|
| Rate for Payer: Aetna Government |
$272.71
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$190.90
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$190.90
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$190.90
|
| Rate for Payer: Brighton Health Commercial |
$233.00
|
| Rate for Payer: Cash Price |
$272.71
|
| Rate for Payer: Cash Price |
$272.71
|
| Rate for Payer: Cash Price |
$272.71
|
| Rate for Payer: Cash Price |
$272.71
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$272.71
|
| 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 |
$272.71
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$231.80
|
| Rate for Payer: Fidelis Essential Plan QHP |
$242.71
|
| Rate for Payer: Fidelis Medicare Advantage |
$272.71
|
| Rate for Payer: Fidelis Qualified Health Plan |
$242.71
|
| 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 |
$326.56
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$272.71
|
| Rate for Payer: Healthfirst Medicare Advantage |
$231.80
|
| Rate for Payer: Healthfirst QHP |
$272.71
|
| Rate for Payer: Humana Medicare |
$278.16
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$272.71
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$272.71
|
| Rate for Payer: United Healthcare Commercial |
$222.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$272.71
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$272.71
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$218.17
|
| Rate for Payer: Wellcare Medicare |
$259.07
|
|
|
CLSD TRMNT SHOULDER DISLOCATION
|
Facility
|
IP
|
$653.13
|
|
|
Service Code
|
HCPCS 23650
|
| Hospital Charge Code |
30100178
|
|
Hospital Revenue Code
|
450
|
| Rate for Payer: Cash Price |
$272.71
|
|
|
CLSD TRMNT SHOULDER DISLOCATION
|
Facility
|
OP
|
$653.13
|
|
|
Service Code
|
HCPCS 23650
|
| Hospital Charge Code |
30100178
|
|
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 |
$272.71
|
| Rate for Payer: Aetna Government |
$272.71
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$190.90
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$190.90
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$190.90
|
| Rate for Payer: Brighton Health Commercial |
$874.00
|
| Rate for Payer: Carelon Behavioral Health CHP/Medicaid |
$272.71
|
| Rate for Payer: Carelon Behavioral Health Medicare Advantage |
$272.71
|
| Rate for Payer: Cash Price |
$272.71
|
| Rate for Payer: Cash Price |
$272.71
|
| Rate for Payer: Cash Price |
$272.71
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$272.71
|
| 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 |
$272.71
|
| Rate for Payer: EmblemHealth Commercial |
$525.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$231.80
|
| Rate for Payer: Fidelis Essential Plan QHP |
$242.71
|
| Rate for Payer: Fidelis Medicare Advantage |
$272.71
|
| Rate for Payer: Fidelis Qualified Health Plan |
$242.71
|
| 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 |
$326.56
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$272.71
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$165.00
|
| Rate for Payer: Healthfirst Medicare Advantage |
$225.00
|
| Rate for Payer: Healthfirst QHP |
$272.71
|
| Rate for Payer: Humana Medicare |
$278.16
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$272.71
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$272.71
|
| Rate for Payer: United Healthcare Commercial |
$569.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$272.71
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$272.71
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$218.17
|
| Rate for Payer: Wellcare Medicare |
$259.07
|
|
