|
COAL TAR 1 % SHAMPOO 177 ML
|
Facility
|
OP
|
$7.56
|
|
| Hospital Charge Code |
41641409
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.65 |
| Max. Negotiated Rate |
$6.05 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$4.16
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3.78
|
| Rate for Payer: Aetna Government |
$3.78
|
| Rate for Payer: Brighton Health Commercial |
$5.67
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$6.05
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$5.14
|
| Rate for Payer: Group Health Inc Commercial |
$3.78
|
| Rate for Payer: Group Health Inc Medicare |
$2.65
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$3.78
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$3.78
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$4.91
|
|
|
COAL TAR 1 % SHAMPOO 177 ML
|
Facility
|
OP
|
$7.56
|
|
| Hospital Charge Code |
41651409
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.65 |
| Max. Negotiated Rate |
$6.05 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$4.16
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3.78
|
| Rate for Payer: Aetna Government |
$3.78
|
| Rate for Payer: Brighton Health Commercial |
$5.67
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$6.05
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$5.14
|
| Rate for Payer: Group Health Inc Commercial |
$3.78
|
| Rate for Payer: Group Health Inc Medicare |
$2.65
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$3.78
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$3.78
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$4.91
|
|
|
COAL TAR EXTRACT 1 % EX SHAM [27671]
|
Facility
|
OP
|
$0.06
|
|
|
Service Code
|
NDC 00187141616
|
| Hospital Charge Code |
00187141616
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.03
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.03
|
| Rate for Payer: Aetna Government |
$0.03
|
| Rate for Payer: Brighton Health Commercial |
$0.04
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.04
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.04
|
| Rate for Payer: Group Health Inc Commercial |
$0.03
|
| Rate for Payer: Group Health Inc Medicare |
$0.02
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.03
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.03
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.04
|
|
|
COAL TAR EXTRACT 1 % EX SHAM [27671]
|
Facility
|
OP
|
$0.04
|
|
|
Service Code
|
NDC 50428030837
|
| Hospital Charge Code |
50428030837
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.02
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.02
|
| Rate for Payer: Aetna Government |
$0.02
|
| Rate for Payer: Brighton Health Commercial |
$0.03
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.03
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.02
|
| Rate for Payer: Group Health Inc Commercial |
$0.02
|
| Rate for Payer: Group Health Inc Medicare |
$0.01
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.02
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.02
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.02
|
|
|
COAXIAL 17G X 11.8
|
Facility
|
OP
|
$41.25
|
|
| Hospital Charge Code |
64903547
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$14.44 |
| Max. Negotiated Rate |
$33.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$22.69
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$20.62
|
| Rate for Payer: Aetna Government |
$20.62
|
| Rate for Payer: Brighton Health Commercial |
$30.94
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$33.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$28.05
|
| Rate for Payer: Group Health Inc Commercial |
$20.62
|
| Rate for Payer: Group Health Inc Medicare |
$14.44
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$20.62
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$20.62
|
|
|
COAXIAL 17G X 16.8
|
Facility
|
OP
|
$34.38
|
|
| Hospital Charge Code |
64903549
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$12.03 |
| Max. Negotiated Rate |
$27.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$18.91
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$17.19
|
| Rate for Payer: Aetna Government |
$17.19
|
| Rate for Payer: Brighton Health Commercial |
$25.78
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$27.50
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$23.38
|
| Rate for Payer: Group Health Inc Commercial |
$17.19
|
| Rate for Payer: Group Health Inc Medicare |
$12.03
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$17.19
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$17.19
|
|
|
COAXIAL 17G X 6.8
|
Facility
|
OP
|
$40.00
|
|
| Hospital Charge Code |
64903545
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$14.00 |
| Max. Negotiated Rate |
$32.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$22.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$20.00
|
| Rate for Payer: Aetna Government |
$20.00
|
| Rate for Payer: Brighton Health Commercial |
$30.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$32.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$27.20
|
| Rate for Payer: Group Health Inc Commercial |
$20.00
|
| Rate for Payer: Group Health Inc Medicare |
$14.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$20.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$20.00
|
|
|
COBALT PLASMA
|
Facility
|
IP
|
$54.90
|
|
|
Service Code
|
HCPCS 83018
|
| Hospital Charge Code |
40609725
|
|
Hospital Revenue Code
|
301
|
| Rate for Payer: Cash Price |
$21.96
|
|
|
COBALT PLASMA
|
Facility
|
OP
|
$54.90
|
|
|
Service Code
|
HCPCS 83018
|
| Hospital Charge Code |
40609725
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$15.37 |
| Max. Negotiated Rate |
$41.18 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$30.20
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$21.96
|
| Rate for Payer: Aetna Government |
$21.96
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$15.37
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$15.37
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$15.37
|
| Rate for Payer: Brighton Health Commercial |
$41.18
|
| Rate for Payer: Cash Price |
$21.96
|
| Rate for Payer: Cash Price |
$21.96
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$21.96
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$34.92
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$29.55
|
| Rate for Payer: Elderplan Medicare Advantage |
$21.96
|
| Rate for Payer: EmblemHealth Commercial |
$21.96
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$18.67
|
| Rate for Payer: Fidelis Essential Plan QHP |
$19.54
|
| Rate for Payer: Fidelis Medicare Advantage |
$21.96
|
| Rate for Payer: Fidelis Qualified Health Plan |
$19.54
|
| Rate for Payer: Group Health Inc Commercial |
$21.96
|
| Rate for Payer: Group Health Inc Medicare |
$21.96
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$27.45
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$21.96
|
| Rate for Payer: Healthfirst Medicare Advantage |
$21.96
|
| Rate for Payer: Healthfirst QHP |
$21.96
|
| Rate for Payer: Humana Medicare |
$22.40
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$21.96
|
| Rate for Payer: United Healthcare Commercial |
$27.82
|
| Rate for Payer: United Healthcare Medicare Advantage |
$21.96
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$21.96
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$17.57
|
| Rate for Payer: Wellcare Medicare |
$19.76
|
|
|
COBAN 2
|
Facility
|
OP
|
$4.68
|
|
| Hospital Charge Code |
40200413
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$1.64 |
| Max. Negotiated Rate |
$3.74 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2.57
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.34
|
| Rate for Payer: Aetna Government |
$2.34
|
| Rate for Payer: Brighton Health Commercial |
$3.51
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$3.74
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$3.18
|
| Rate for Payer: Group Health Inc Commercial |
$2.34
|
| Rate for Payer: Group Health Inc Medicare |
$1.64
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.34
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2.34
|
|
|
COBAN STERILE 3
|
Facility
|
OP
|
$4.68
|
|
| Hospital Charge Code |
40200414
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$1.64 |
| Max. Negotiated Rate |
$3.74 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2.57
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.34
|
| Rate for Payer: Aetna Government |
$2.34
|
| Rate for Payer: Brighton Health Commercial |
$3.51
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$3.74
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$3.18
|
| Rate for Payer: Group Health Inc Commercial |
$2.34
|
| Rate for Payer: Group Health Inc Medicare |
$1.64
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.34
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2.34
|
|
|
COBAN STERILE 4
|
Facility
|
OP
|
$4.68
|
|
| Hospital Charge Code |
40200415
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$1.64 |
| Max. Negotiated Rate |
$3.74 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2.57
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.34
|
| Rate for Payer: Aetna Government |
$2.34
|
| Rate for Payer: Brighton Health Commercial |
$3.51
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$3.74
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$3.18
|
| Rate for Payer: Group Health Inc Commercial |
$2.34
|
| Rate for Payer: Group Health Inc Medicare |
$1.64
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.34
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2.34
|
|
|
COBAN WRAP 3 NON-STERILE
|
Facility
|
OP
|
$3.83
|
|
| Hospital Charge Code |
64903209
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$1.34 |
| Max. Negotiated Rate |
$3.06 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2.11
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.92
|
| Rate for Payer: Aetna Government |
$1.92
|
| Rate for Payer: Brighton Health Commercial |
$2.87
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$3.06
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2.60
|
| Rate for Payer: Group Health Inc Commercial |
$1.92
|
| Rate for Payer: Group Health Inc Medicare |
$1.34
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.92
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.92
|
|
|
COBAN WRAP 3 STERILE
|
Facility
|
OP
|
$3.44
|
|
| Hospital Charge Code |
64902834
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$1.20 |
| Max. Negotiated Rate |
$2.75 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.89
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.72
|
| Rate for Payer: Aetna Government |
$1.72
|
| Rate for Payer: Brighton Health Commercial |
$2.58
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2.75
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2.34
|
| Rate for Payer: Group Health Inc Commercial |
$1.72
|
| Rate for Payer: Group Health Inc Medicare |
$1.20
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.72
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.72
|
|
|
COBICISTAT 150MG
|
Facility
|
OP
|
$17.13
|
|
| Hospital Charge Code |
41647814
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.00 |
| Max. Negotiated Rate |
$13.70 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$9.42
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$8.56
|
| Rate for Payer: Aetna Government |
$8.56
|
| Rate for Payer: Brighton Health Commercial |
$12.85
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$13.70
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$11.65
|
| Rate for Payer: Group Health Inc Commercial |
$8.56
|
| Rate for Payer: Group Health Inc Medicare |
$6.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$8.56
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$8.56
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$11.13
|
|
|
COBICISTAT 150MG
|
Facility
|
OP
|
$17.13
|
|
| Hospital Charge Code |
41657814
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.00 |
| Max. Negotiated Rate |
$13.70 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$9.42
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$8.56
|
| Rate for Payer: Aetna Government |
$8.56
|
| Rate for Payer: Brighton Health Commercial |
$12.85
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$13.70
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$11.65
|
| Rate for Payer: Group Health Inc Commercial |
$8.56
|
| Rate for Payer: Group Health Inc Medicare |
$6.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$8.56
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$8.56
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$11.13
|
|
|
COCAINE 4% 10ML TOPICAL
|
Facility
|
OP
|
$709.48
|
|
| Hospital Charge Code |
41648175
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$248.32 |
| Max. Negotiated Rate |
$567.58 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$390.21
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$354.74
|
| Rate for Payer: Aetna Government |
$354.74
|
| Rate for Payer: Brighton Health Commercial |
$532.11
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$567.58
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$482.45
|
| Rate for Payer: Group Health Inc Commercial |
$354.74
|
| Rate for Payer: Group Health Inc Medicare |
$248.32
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$354.74
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$354.74
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$461.16
|
|
|
COCAINE 4% 10ML TOPICAL
|
Facility
|
OP
|
$709.48
|
|
| Hospital Charge Code |
41658175
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$248.32 |
| Max. Negotiated Rate |
$567.58 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$390.21
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$354.74
|
| Rate for Payer: Aetna Government |
$354.74
|
| Rate for Payer: Brighton Health Commercial |
$532.11
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$567.58
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$482.45
|
| Rate for Payer: Group Health Inc Commercial |
$354.74
|
| Rate for Payer: Group Health Inc Medicare |
$248.32
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$354.74
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$354.74
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$461.16
|
|
|
COCAINE HCL 40 MG/ML NA SOLN [160308]
|
Facility
|
OP
|
$66.15
|
|
|
Service Code
|
NDC 00527197174
|
| Hospital Charge Code |
00527197174
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.15 |
| Max. Negotiated Rate |
$52.92 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$36.38
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$33.08
|
| Rate for Payer: Aetna Government |
$33.08
|
| Rate for Payer: Brighton Health Commercial |
$49.61
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$52.92
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$44.98
|
| Rate for Payer: Group Health Inc Commercial |
$33.08
|
| Rate for Payer: Group Health Inc Medicare |
$23.15
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$33.08
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$33.08
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$43.00
|
|
|
COCAINE HCL 40 MG/ML NA SOLN [160308]
|
Facility
|
OP
|
$73.50
|
|
|
Service Code
|
NDC 64950036204
|
| Hospital Charge Code |
64950036204
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.72 |
| Max. Negotiated Rate |
$58.80 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$40.42
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$36.75
|
| Rate for Payer: Aetna Government |
$36.75
|
| Rate for Payer: Brighton Health Commercial |
$55.12
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$58.80
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$49.98
|
| Rate for Payer: Group Health Inc Commercial |
$36.75
|
| Rate for Payer: Group Health Inc Medicare |
$25.72
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$36.75
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$36.75
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$47.78
|
|
|
COCAINE METABOLITE CONFIRM,UR
|
Facility
|
OP
|
$49.93
|
|
|
Service Code
|
HCPCS 80353
|
| Hospital Charge Code |
40609839
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$39.94 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$27.46
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.01
|
| Rate for Payer: Aetna Government |
$0.01
|
| Rate for Payer: Brighton Health Commercial |
$37.45
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$39.94
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$33.95
|
| Rate for Payer: Group Health Inc Commercial |
$24.96
|
| Rate for Payer: Group Health Inc Medicare |
$17.48
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$24.96
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$24.96
|
| Rate for Payer: United Healthcare Commercial |
$18.56
|
|
|
COCAINE TOPICAL 4% SOLUTION
|
Facility
|
OP
|
$106.56
|
|
| Hospital Charge Code |
41654101
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.30 |
| Max. Negotiated Rate |
$85.25 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$58.61
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$53.28
|
| Rate for Payer: Aetna Government |
$53.28
|
| Rate for Payer: Brighton Health Commercial |
$79.92
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$85.25
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$72.46
|
| Rate for Payer: Group Health Inc Commercial |
$53.28
|
| Rate for Payer: Group Health Inc Medicare |
$37.30
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$53.28
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$53.28
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$69.26
|
|
|
COCAINE TOPICAL 4% SOLUTION
|
Facility
|
OP
|
$106.56
|
|
| Hospital Charge Code |
41644101
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.30 |
| Max. Negotiated Rate |
$85.25 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$58.61
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$53.28
|
| Rate for Payer: Aetna Government |
$53.28
|
| Rate for Payer: Brighton Health Commercial |
$79.92
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$85.25
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$72.46
|
| Rate for Payer: Group Health Inc Commercial |
$53.28
|
| Rate for Payer: Group Health Inc Medicare |
$37.30
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$53.28
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$53.28
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$69.26
|
|
|
COCCIDIOIDES IMMITIS ABS
|
Facility
|
OP
|
$28.68
|
|
|
Service Code
|
HCPCS 86635
|
| Hospital Charge Code |
40729354
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.03 |
| Max. Negotiated Rate |
$21.51 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$15.77
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$11.47
|
| Rate for Payer: Aetna Government |
$11.47
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$8.03
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$8.03
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$8.03
|
| Rate for Payer: Brighton Health Commercial |
$21.51
|
| Rate for Payer: Cash Price |
$11.47
|
| Rate for Payer: Cash Price |
$11.47
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$11.47
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$18.25
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$15.44
|
| Rate for Payer: Elderplan Medicare Advantage |
$11.47
|
| Rate for Payer: EmblemHealth Commercial |
$11.47
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$9.75
|
| Rate for Payer: Fidelis Essential Plan QHP |
$10.21
|
| Rate for Payer: Fidelis Medicare Advantage |
$11.47
|
| Rate for Payer: Fidelis Qualified Health Plan |
$10.21
|
| Rate for Payer: Group Health Inc Commercial |
$11.47
|
| Rate for Payer: Group Health Inc Medicare |
$11.47
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$14.34
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$11.47
|
| Rate for Payer: Healthfirst Medicare Advantage |
$11.47
|
| Rate for Payer: Healthfirst QHP |
$11.47
|
| Rate for Payer: Humana Medicare |
$11.70
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$11.47
|
| Rate for Payer: United Healthcare Commercial |
$14.54
|
| Rate for Payer: United Healthcare Medicare Advantage |
$11.47
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$11.47
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$9.18
|
| Rate for Payer: Wellcare Medicare |
$10.32
|
|
|
COCCIDIOIDES IMMITIS ABS
|
Facility
|
IP
|
$28.68
|
|
|
Service Code
|
HCPCS 86635
|
| Hospital Charge Code |
40729354
|
|
Hospital Revenue Code
|
300
|
| Rate for Payer: Cash Price |
$11.47
|
|
