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All Charges

Charge

Type

Setting

Price

ACYCLOVIR 800 MG TAB

Facility

IP

$0.29

Service Code	HCPCS J8499
Hospital Charge Code	41643578
Hospital Revenue Code	636
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.15
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.15
Rate for Payer: Hamaspik Choice Inc Medicare	$0.15

ACYCLOVIR 800 MG TAB

Facility

OP

$0.29

Service Code	HCPCS J8499
Hospital Charge Code	41653578
Hospital Revenue Code	636
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.19
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.16
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.15
Rate for Payer: Aetna Government	$0.15
Rate for Payer: Brighton Health Commercial	$0.17
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.15
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.17
Rate for Payer: Group Health Inc Commercial	$0.15
Rate for Payer: Group Health Inc Medicare	$0.10
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.15
Rate for Payer: Hamaspik Choice Inc Medicare	$0.15
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.19

ACYCLOVIR 800 MG TAB

Facility

OP

$0.29

Service Code	HCPCS J8499
Hospital Charge Code	41643578
Hospital Revenue Code	636
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.19
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.16
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.15
Rate for Payer: Aetna Government	$0.15
Rate for Payer: Brighton Health Commercial	$0.17
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.15
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.17
Rate for Payer: Group Health Inc Commercial	$0.15
Rate for Payer: Group Health Inc Medicare	$0.10
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.15
Rate for Payer: Hamaspik Choice Inc Medicare	$0.15
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.19

ACYCLOVIR IV SYRINGE 5 MG/ML (NEO/PED) [401234]

Facility

IP

$39.38

Service Code	NDC 09999123454
Hospital Charge Code	39822019001
Hospital Revenue Code	278
Min. Negotiated Rate	$19.69
Max. Negotiated Rate	$19.69
Rate for Payer: Hamaspik Choice Inc Medicaid	$19.69
Rate for Payer: Hamaspik Choice Inc Medicare	$19.69

ACYCLOVIR IV SYRINGE 5 MG/ML (NEO/PED) [401234]

Facility

OP

$39.38

Service Code	NDC 09999123454
Hospital Charge Code	39822019001
Hospital Revenue Code	278
Min. Negotiated Rate	$13.78
Max. Negotiated Rate	$41.35
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$21.66
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$19.69
Rate for Payer: Aetna Government	$19.69
Rate for Payer: Brighton Health Commercial	$23.63
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$19.69
Rate for Payer: Cigna LocalPlus Benefit Plan	$22.64
Rate for Payer: EmblemHealth Commercial	$19.69
Rate for Payer: Fidelis Medicare Advantage	$41.35
Rate for Payer: Group Health Inc Commercial	$19.69
Rate for Payer: Group Health Inc Medicare	$13.78
Rate for Payer: Hamaspik Choice Inc Medicaid	$19.69
Rate for Payer: Hamaspik Choice Inc Medicare	$19.69
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$25.60

ACYCLOVIR SODIUM 50 MG/ML IV SOLN [23128]

Facility

OP

$2.26

Service Code	HCPCS J0133
Hospital Charge Code	63323032510
Hospital Revenue Code	278
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$2.37
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.24
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.04
Rate for Payer: Aetna Government	$0.04
Rate for Payer: Brighton Health Commercial	$1.35
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.13
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.30
Rate for Payer: EmblemHealth Commercial	$1.13
Rate for Payer: Fidelis Medicare Advantage	$2.37
Rate for Payer: Group Health Inc Commercial	$1.13
Rate for Payer: Group Health Inc Medicare	$0.79
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.13
Rate for Payer: Hamaspik Choice Inc Medicare	$1.13
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.47

ACYCLOVIR SODIUM 50 MG/ML IV SOLN [23128]

Facility

OP

$2.26

Service Code	HCPCS J0133
Hospital Charge Code	63323032503
Hospital Revenue Code	278
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$2.37
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.24
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.04
Rate for Payer: Aetna Government	$0.04
Rate for Payer: Brighton Health Commercial	$1.35
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.13
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.30
Rate for Payer: EmblemHealth Commercial	$1.13
Rate for Payer: Fidelis Medicare Advantage	$2.37
Rate for Payer: Group Health Inc Commercial	$1.13
Rate for Payer: Group Health Inc Medicare	$0.79
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.13
Rate for Payer: Hamaspik Choice Inc Medicare	$1.13
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.47

ACYCLOVIR SODIUM 50 MG/ML IV SOLN [23128]

Facility

OP

$0.52

Service Code	HCPCS J0133
Hospital Charge Code	63323032514
Hospital Revenue Code	278
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.54
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.28
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.04
Rate for Payer: Aetna Government	$0.04
Rate for Payer: Brighton Health Commercial	$0.31
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.26
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.30
Rate for Payer: EmblemHealth Commercial	$0.26
Rate for Payer: Fidelis Medicare Advantage	$0.54
Rate for Payer: Group Health Inc Commercial	$0.26
Rate for Payer: Group Health Inc Medicare	$0.18
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.26
Rate for Payer: Hamaspik Choice Inc Medicare	$0.26
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.34

ACYCLOVIR SODIUM 50 MG/ML IV SOLN [23128]

Facility

OP

$1.60

Service Code	HCPCS J0133
Hospital Charge Code	55150015410
Hospital Revenue Code	278
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$1.68
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.88
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.04
Rate for Payer: Aetna Government	$0.04
Rate for Payer: Brighton Health Commercial	$0.96
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.80
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.92
Rate for Payer: EmblemHealth Commercial	$0.80
Rate for Payer: Fidelis Medicare Advantage	$1.68
Rate for Payer: Group Health Inc Commercial	$0.80
Rate for Payer: Group Health Inc Medicare	$0.56
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.80
Rate for Payer: Hamaspik Choice Inc Medicare	$0.80
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.04

ACYCLOVIR SODIUM 50 MG/ML IV SOLN [23128]

Facility

OP

$1.50

Service Code	HCPCS J0133
Hospital Charge Code	55150015520
Hospital Revenue Code	278
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$1.58
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.83
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.04
Rate for Payer: Aetna Government	$0.04
Rate for Payer: Brighton Health Commercial	$0.90
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.75
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.86
Rate for Payer: EmblemHealth Commercial	$0.75
Rate for Payer: Fidelis Medicare Advantage	$1.58
Rate for Payer: Group Health Inc Commercial	$0.75
Rate for Payer: Group Health Inc Medicare	$0.53
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.75
Rate for Payer: Hamaspik Choice Inc Medicare	$0.75
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.98

ACYCLOVIR SODIUM 50 MG/ML IV SOLN [23128]

Facility

IP

$0.52

Service Code	HCPCS J0133
Hospital Charge Code	63323032524
Hospital Revenue Code	278
Min. Negotiated Rate	$0.26
Max. Negotiated Rate	$0.26
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.26
Rate for Payer: Hamaspik Choice Inc Medicare	$0.26

ACYCLOVIR SODIUM 50 MG/ML IV SOLN [23128]

Facility

OP

$2.10

Service Code	HCPCS J0133
Hospital Charge Code	63323032509
Hospital Revenue Code	278
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$2.20
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.16
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.04
Rate for Payer: Aetna Government	$0.04
Rate for Payer: Brighton Health Commercial	$1.26
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.05
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.21
Rate for Payer: EmblemHealth Commercial	$1.05
Rate for Payer: Fidelis Medicare Advantage	$2.20
Rate for Payer: Group Health Inc Commercial	$1.05
Rate for Payer: Group Health Inc Medicare	$0.74
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.05
Rate for Payer: Hamaspik Choice Inc Medicare	$1.05
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.36

ACYCLOVIR SODIUM 50 MG/ML IV SOLN [23128]

Facility

IP

$2.26

Service Code	HCPCS J0133
Hospital Charge Code	63323032503
Hospital Revenue Code	278
Min. Negotiated Rate	$1.13
Max. Negotiated Rate	$1.13
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.13
Rate for Payer: Hamaspik Choice Inc Medicare	$1.13

ACYCLOVIR SODIUM 50 MG/ML IV SOLN [23128]

Facility

IP

$2.26

Service Code	HCPCS J0133
Hospital Charge Code	63323032510
Hospital Revenue Code	278
Min. Negotiated Rate	$1.13
Max. Negotiated Rate	$1.13
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.13
Rate for Payer: Hamaspik Choice Inc Medicare	$1.13

ACYCLOVIR SODIUM 50 MG/ML IV SOLN [23128]

Facility

OP

$0.52

Service Code	HCPCS J0133
Hospital Charge Code	63323032524
Hospital Revenue Code	278
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.54
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.28
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.04
Rate for Payer: Aetna Government	$0.04
Rate for Payer: Brighton Health Commercial	$0.31
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.26
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.30
Rate for Payer: EmblemHealth Commercial	$0.26
Rate for Payer: Fidelis Medicare Advantage	$0.54
Rate for Payer: Group Health Inc Commercial	$0.26
Rate for Payer: Group Health Inc Medicare	$0.18
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.26
Rate for Payer: Hamaspik Choice Inc Medicare	$0.26
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.34

ACYCLOVIR SODIUM 50 MG/ML IV SOLN [23128]

Facility

IP

$1.60

Service Code	HCPCS J0133
Hospital Charge Code	55150015410
Hospital Revenue Code	278
Min. Negotiated Rate	$0.80
Max. Negotiated Rate	$0.80
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.80
Rate for Payer: Hamaspik Choice Inc Medicare	$0.80

ACYCLOVIR SODIUM 50 MG/ML IV SOLN [23128]

Facility

IP

$0.52

Service Code	HCPCS J0133
Hospital Charge Code	63323032514
Hospital Revenue Code	278
Min. Negotiated Rate	$0.26
Max. Negotiated Rate	$0.26
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.26
Rate for Payer: Hamaspik Choice Inc Medicare	$0.26

ACYCLOVIR SODIUM 50 MG/ML IV SOLN [23128]

Facility

IP

$2.10

Service Code	HCPCS J0133
Hospital Charge Code	63323032520
Hospital Revenue Code	278
Min. Negotiated Rate	$1.05
Max. Negotiated Rate	$1.05
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.05
Rate for Payer: Hamaspik Choice Inc Medicare	$1.05

ACYCLOVIR SODIUM 50 MG/ML IV SOLN [23128]

Facility

IP

$1.50

Service Code	HCPCS J0133
Hospital Charge Code	55150015520
Hospital Revenue Code	278
Min. Negotiated Rate	$0.75
Max. Negotiated Rate	$0.75
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.75
Rate for Payer: Hamaspik Choice Inc Medicare	$0.75

ACYCLOVIR SODIUM 50 MG/ML IV SOLN [23128]

Facility

IP

$2.10

Service Code	HCPCS J0133
Hospital Charge Code	63323032509
Hospital Revenue Code	278
Min. Negotiated Rate	$1.05
Max. Negotiated Rate	$1.05
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.05
Rate for Payer: Hamaspik Choice Inc Medicare	$1.05

ACYCLOVIR SODIUM 50 MG/ML IV SOLN [23128]

Facility

OP

$2.10

Service Code	HCPCS J0133
Hospital Charge Code	63323032520
Hospital Revenue Code	278
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$2.20
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.16
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.04
Rate for Payer: Aetna Government	$0.04
Rate for Payer: Brighton Health Commercial	$1.26
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.05
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.21
Rate for Payer: EmblemHealth Commercial	$1.05
Rate for Payer: Fidelis Medicare Advantage	$2.20
Rate for Payer: Group Health Inc Commercial	$1.05
Rate for Payer: Group Health Inc Medicare	$0.74
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.05
Rate for Payer: Hamaspik Choice Inc Medicare	$1.05
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.36

ADAMTS13 ACTIVITY REFLEX PANEL

Facility

OP

$420.00

Hospital Charge Code	40629846
Hospital Revenue Code	305
Min. Negotiated Rate	$147.00
Max. Negotiated Rate	$336.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$231.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$210.00
Rate for Payer: Aetna Government	$210.00
Rate for Payer: Brighton Health Commercial	$315.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$336.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$285.60
Rate for Payer: Group Health Inc Commercial	$210.00
Rate for Payer: Group Health Inc Medicare	$147.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$210.00
Rate for Payer: Hamaspik Choice Inc Medicare	$210.00

ADAPTA PACEMAKER

Facility

OP

$8,016.00

Service Code	HCPCS C1786
Hospital Charge Code	66574083
Hospital Revenue Code	275
Min. Negotiated Rate	$1,116.69
Max. Negotiated Rate	$8,416.80
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$4,408.80
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,116.69
Rate for Payer: Aetna Government	$1,116.69
Rate for Payer: Brighton Health Commercial	$4,809.60
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$4,008.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$4,609.20
Rate for Payer: EmblemHealth Commercial	$4,008.00
Rate for Payer: Fidelis Medicare Advantage	$8,416.80
Rate for Payer: Group Health Inc Commercial	$4,008.00
Rate for Payer: Group Health Inc Medicare	$2,805.60
Rate for Payer: Hamaspik Choice Inc Medicaid	$4,008.00
Rate for Payer: Hamaspik Choice Inc Medicare	$4,008.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$5,210.40

ADAPTER AIRWAY ADULT

Facility

OP

$5.44

Hospital Charge Code	64903892
Hospital Revenue Code	270
Min. Negotiated Rate	$1.90
Max. Negotiated Rate	$4.35
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2.99
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2.72
Rate for Payer: Aetna Government	$2.72
Rate for Payer: Brighton Health Commercial	$4.08
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$4.35
Rate for Payer: Cigna LocalPlus Benefit Plan	$3.70
Rate for Payer: Group Health Inc Commercial	$2.72
Rate for Payer: Group Health Inc Medicare	$1.90
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.72
Rate for Payer: Hamaspik Choice Inc Medicare	$2.72

ADAPTER,AIRWAY,DASH,CAPNO

Facility

OP

$201.65

Hospital Charge Code	64903683
Hospital Revenue Code	270
Min. Negotiated Rate	$70.58
Max. Negotiated Rate	$161.32
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$110.91
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$100.82
Rate for Payer: Aetna Government	$100.82
Rate for Payer: Brighton Health Commercial	$151.24
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$161.32
Rate for Payer: Cigna LocalPlus Benefit Plan	$137.12
Rate for Payer: Group Health Inc Commercial	$100.82
Rate for Payer: Group Health Inc Medicare	$70.58
Rate for Payer: Hamaspik Choice Inc Medicaid	$100.82
Rate for Payer: Hamaspik Choice Inc Medicare	$100.82

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