|
BORTEZOMIB 3.5 MG IJ SOLR
|
Facility
|
IP
|
$50.40
|
|
|
Service Code
|
HCPCS J9041
|
| Hospital Charge Code |
7128811810
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.20 |
| Max. Negotiated Rate |
$25.20 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$25.20
|
|
|
BPD & oth chronic respiratory diseases arising in perinatal period
|
Facility
|
IP
|
$45,810.52
|
|
|
Service Code
|
APR-DRG 1322
|
| Min. Negotiated Rate |
$9,279.00 |
| Max. Negotiated Rate |
$45,810.52 |
| Rate for Payer: Affinity Essential Plan 1&2 |
$45,810.52
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$45,810.52
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$20,360.23
|
| Rate for Payer: Amida Care Medicaid |
$20,360.23
|
| Rate for Payer: EmblemHealth Essential Plan 1&2 |
$45,810.52
|
| Rate for Payer: EmblemHealth Essential Plan 3&4 |
$20,360.23
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$20,360.23
|
| Rate for Payer: Fidelis Qualified Health Plan |
$24,432.28
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$20,360.23
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$20,360.23
|
| Rate for Payer: Healthfirst Commercial |
$15,390.00
|
| Rate for Payer: Healthfirst Essential Plan |
$45,810.52
|
| Rate for Payer: Healthfirst QHP |
$9,279.00
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$20,360.23
|
| Rate for Payer: SOMOS Essential |
$45,810.52
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$45,810.52
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$45,810.52
|
| Rate for Payer: United Healthcare Medicaid |
$20,360.23
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$20,360.23
|
|
|
BPD & oth chronic respiratory diseases arising in perinatal period
|
Facility
|
IP
|
$55,191.67
|
|
|
Service Code
|
APR-DRG 1323
|
| Min. Negotiated Rate |
$14,354.00 |
| Max. Negotiated Rate |
$55,191.67 |
| Rate for Payer: Affinity Essential Plan 1&2 |
$55,191.67
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$55,191.67
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$24,529.63
|
| Rate for Payer: Amida Care Medicaid |
$24,529.63
|
| Rate for Payer: EmblemHealth Essential Plan 1&2 |
$55,191.67
|
| Rate for Payer: EmblemHealth Essential Plan 3&4 |
$24,529.63
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$24,529.63
|
| Rate for Payer: Fidelis Qualified Health Plan |
$29,435.56
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$24,529.63
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$24,529.63
|
| Rate for Payer: Healthfirst Commercial |
$22,727.00
|
| Rate for Payer: Healthfirst Essential Plan |
$55,191.67
|
| Rate for Payer: Healthfirst QHP |
$14,354.00
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$24,529.63
|
| Rate for Payer: SOMOS Essential |
$55,191.67
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$55,191.67
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$55,191.67
|
| Rate for Payer: United Healthcare Medicaid |
$24,529.63
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$24,529.63
|
|
|
BPD & oth chronic respiratory diseases arising in perinatal period
|
Facility
|
IP
|
$42,396.79
|
|
|
Service Code
|
APR-DRG 1321
|
| Min. Negotiated Rate |
$7,497.00 |
| Max. Negotiated Rate |
$42,396.79 |
| Rate for Payer: Affinity Essential Plan 1&2 |
$42,396.79
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$42,396.79
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$18,843.02
|
| Rate for Payer: Amida Care Medicaid |
$18,843.02
|
| Rate for Payer: EmblemHealth Essential Plan 1&2 |
$42,396.79
|
| Rate for Payer: EmblemHealth Essential Plan 3&4 |
$18,843.02
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$18,843.02
|
| Rate for Payer: Fidelis Qualified Health Plan |
$22,611.62
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$18,843.02
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$18,843.02
|
| Rate for Payer: Healthfirst Commercial |
$12,698.00
|
| Rate for Payer: Healthfirst Essential Plan |
$42,396.79
|
| Rate for Payer: Healthfirst QHP |
$7,497.00
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$18,843.02
|
| Rate for Payer: SOMOS Essential |
$42,396.79
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$42,396.79
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$42,396.79
|
| Rate for Payer: United Healthcare Medicaid |
$18,843.02
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$18,843.02
|
|
|
BPD & oth chronic respiratory diseases arising in perinatal period
|
Facility
|
IP
|
$74,240.64
|
|
|
Service Code
|
APR-DRG 1324
|
| Min. Negotiated Rate |
$26,302.00 |
| Max. Negotiated Rate |
$74,240.64 |
| Rate for Payer: Affinity Essential Plan 1&2 |
$74,240.64
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$74,240.64
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$32,995.84
|
| Rate for Payer: Amida Care Medicaid |
$32,995.84
|
| Rate for Payer: EmblemHealth Essential Plan 1&2 |
$74,240.64
|
| Rate for Payer: EmblemHealth Essential Plan 3&4 |
$32,995.84
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$32,995.84
|
| Rate for Payer: Fidelis Qualified Health Plan |
$39,595.01
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$32,995.84
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$32,995.84
|
| Rate for Payer: Healthfirst Commercial |
$44,693.00
|
| Rate for Payer: Healthfirst Essential Plan |
$74,240.64
|
| Rate for Payer: Healthfirst QHP |
$26,302.00
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$32,995.84
|
| Rate for Payer: SOMOS Essential |
$74,240.64
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$74,240.64
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$74,240.64
|
| Rate for Payer: United Healthcare Medicaid |
$32,995.84
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$32,995.84
|
|
|
Brain contusion/laceration & complicated skull Fx, coma < 1 hr or no coma
|
Facility
|
IP
|
$46,114.79
|
|
|
Service Code
|
APR-DRG 0562
|
| Min. Negotiated Rate |
$8,707.00 |
| Max. Negotiated Rate |
$46,114.79 |
| Rate for Payer: Affinity Essential Plan 1&2 |
$46,114.79
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$46,114.79
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$20,495.46
|
| Rate for Payer: Amida Care Medicaid |
$20,495.46
|
| Rate for Payer: EmblemHealth Essential Plan 1&2 |
$46,114.79
|
| Rate for Payer: EmblemHealth Essential Plan 3&4 |
$20,495.46
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$20,495.46
|
| Rate for Payer: Fidelis Qualified Health Plan |
$24,594.55
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$20,495.46
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$20,495.46
|
| Rate for Payer: Healthfirst Commercial |
$14,748.00
|
| Rate for Payer: Healthfirst Essential Plan |
$46,114.79
|
| Rate for Payer: Healthfirst QHP |
$8,707.00
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$20,495.46
|
| Rate for Payer: SOMOS Essential |
$46,114.79
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$46,114.79
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$46,114.79
|
| Rate for Payer: United Healthcare Medicaid |
$20,495.46
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$20,495.46
|
|
|
Brain contusion/laceration & complicated skull Fx, coma < 1 hr or no coma
|
Facility
|
IP
|
$98,919.38
|
|
|
Service Code
|
APR-DRG 0564
|
| Min. Negotiated Rate |
$43,707.00 |
| Max. Negotiated Rate |
$98,919.38 |
| Rate for Payer: Affinity Essential Plan 1&2 |
$98,919.38
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$98,919.38
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$43,964.17
|
| Rate for Payer: Amida Care Medicaid |
$43,964.17
|
| Rate for Payer: EmblemHealth Essential Plan 1&2 |
$98,919.38
|
| Rate for Payer: EmblemHealth Essential Plan 3&4 |
$43,964.17
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$43,964.17
|
| Rate for Payer: Fidelis Qualified Health Plan |
$52,757.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$43,964.17
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$43,964.17
|
| Rate for Payer: Healthfirst Commercial |
$73,746.00
|
| Rate for Payer: Healthfirst Essential Plan |
$98,919.38
|
| Rate for Payer: Healthfirst QHP |
$43,707.00
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$43,964.17
|
| Rate for Payer: SOMOS Essential |
$98,919.38
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$98,919.38
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$98,919.38
|
| Rate for Payer: United Healthcare Medicaid |
$43,964.17
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$43,964.17
|
|
|
Brain contusion/laceration & complicated skull Fx, coma < 1 hr or no coma
|
Facility
|
IP
|
$41,149.85
|
|
|
Service Code
|
APR-DRG 0561
|
| Min. Negotiated Rate |
$6,276.00 |
| Max. Negotiated Rate |
$41,149.85 |
| Rate for Payer: Affinity Essential Plan 1&2 |
$41,149.85
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$41,149.85
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$18,288.82
|
| Rate for Payer: Amida Care Medicaid |
$18,288.82
|
| Rate for Payer: EmblemHealth Essential Plan 1&2 |
$41,149.85
|
| Rate for Payer: EmblemHealth Essential Plan 3&4 |
$18,288.82
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$18,288.82
|
| Rate for Payer: Fidelis Qualified Health Plan |
$21,946.58
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$18,288.82
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$18,288.82
|
| Rate for Payer: Healthfirst Commercial |
$10,097.00
|
| Rate for Payer: Healthfirst Essential Plan |
$41,149.85
|
| Rate for Payer: Healthfirst QHP |
$6,276.00
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$18,288.82
|
| Rate for Payer: SOMOS Essential |
$41,149.85
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$41,149.85
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$41,149.85
|
| Rate for Payer: United Healthcare Medicaid |
$18,288.82
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$18,288.82
|
|
|
Brain contusion/laceration & complicated skull Fx, coma < 1 hr or no coma
|
Facility
|
IP
|
$57,108.69
|
|
|
Service Code
|
APR-DRG 0563
|
| Min. Negotiated Rate |
$16,480.00 |
| Max. Negotiated Rate |
$57,108.69 |
| Rate for Payer: Affinity Essential Plan 1&2 |
$57,108.69
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$57,108.69
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$25,381.64
|
| Rate for Payer: Amida Care Medicaid |
$25,381.64
|
| Rate for Payer: EmblemHealth Essential Plan 1&2 |
$57,108.69
|
| Rate for Payer: EmblemHealth Essential Plan 3&4 |
$25,381.64
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$25,381.64
|
| Rate for Payer: Fidelis Qualified Health Plan |
$30,457.97
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$25,381.64
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$25,381.64
|
| Rate for Payer: Healthfirst Commercial |
$25,023.00
|
| Rate for Payer: Healthfirst Essential Plan |
$57,108.69
|
| Rate for Payer: Healthfirst QHP |
$16,480.00
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$25,381.64
|
| Rate for Payer: SOMOS Essential |
$57,108.69
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$57,108.69
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$57,108.69
|
| Rate for Payer: United Healthcare Medicaid |
$25,381.64
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$25,381.64
|
|
|
Breast procedures except mastectomy
|
Facility
|
IP
|
$72,385.18
|
|
|
Service Code
|
APR-DRG 3633
|
| Min. Negotiated Rate |
$20,455.00 |
| Max. Negotiated Rate |
$72,385.18 |
| Rate for Payer: Affinity Essential Plan 1&2 |
$72,385.18
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$72,385.18
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$32,171.19
|
| Rate for Payer: Amida Care Medicaid |
$32,171.19
|
| Rate for Payer: EmblemHealth Essential Plan 1&2 |
$72,385.18
|
| Rate for Payer: EmblemHealth Essential Plan 3&4 |
$32,171.19
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$32,171.19
|
| Rate for Payer: Fidelis Qualified Health Plan |
$38,605.43
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$32,171.19
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$32,171.19
|
| Rate for Payer: Healthfirst Commercial |
$34,640.00
|
| Rate for Payer: Healthfirst Essential Plan |
$72,385.18
|
| Rate for Payer: Healthfirst QHP |
$20,455.00
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$32,171.19
|
| Rate for Payer: SOMOS Essential |
$72,385.18
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$72,385.18
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$72,385.18
|
| Rate for Payer: United Healthcare Medicaid |
$32,171.19
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$32,171.19
|
|
|
Breast procedures except mastectomy
|
Facility
|
IP
|
$47,938.59
|
|
|
Service Code
|
APR-DRG 3631
|
| Min. Negotiated Rate |
$9,129.00 |
| Max. Negotiated Rate |
$47,938.59 |
| Rate for Payer: Affinity Essential Plan 1&2 |
$47,938.59
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$47,938.59
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$21,306.04
|
| Rate for Payer: Amida Care Medicaid |
$21,306.04
|
| Rate for Payer: EmblemHealth Essential Plan 1&2 |
$47,938.59
|
| Rate for Payer: EmblemHealth Essential Plan 3&4 |
$21,306.04
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$21,306.04
|
| Rate for Payer: Fidelis Qualified Health Plan |
$25,567.25
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$21,306.04
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$21,306.04
|
| Rate for Payer: Healthfirst Commercial |
$16,146.00
|
| Rate for Payer: Healthfirst Essential Plan |
$47,938.59
|
| Rate for Payer: Healthfirst QHP |
$9,129.00
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$21,306.04
|
| Rate for Payer: SOMOS Essential |
$47,938.59
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$47,938.59
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$47,938.59
|
| Rate for Payer: United Healthcare Medicaid |
$21,306.04
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$21,306.04
|
|
|
Breast procedures except mastectomy
|
Facility
|
IP
|
$73,528.36
|
|
|
Service Code
|
APR-DRG 3634
|
| Min. Negotiated Rate |
$21,670.00 |
| Max. Negotiated Rate |
$73,528.36 |
| Rate for Payer: Affinity Essential Plan 1&2 |
$73,528.36
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$73,528.36
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$32,679.27
|
| Rate for Payer: Amida Care Medicaid |
$32,679.27
|
| Rate for Payer: EmblemHealth Essential Plan 1&2 |
$73,528.36
|
| Rate for Payer: EmblemHealth Essential Plan 3&4 |
$32,679.27
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$32,679.27
|
| Rate for Payer: Fidelis Qualified Health Plan |
$39,215.12
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$32,679.27
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$32,679.27
|
| Rate for Payer: Healthfirst Commercial |
$36,316.00
|
| Rate for Payer: Healthfirst Essential Plan |
$73,528.36
|
| Rate for Payer: Healthfirst QHP |
$21,670.00
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$32,679.27
|
| Rate for Payer: SOMOS Essential |
$73,528.36
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$73,528.36
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$73,528.36
|
| Rate for Payer: United Healthcare Medicaid |
$32,679.27
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$32,679.27
|
|
|
Breast procedures except mastectomy
|
Facility
|
IP
|
$58,721.47
|
|
|
Service Code
|
APR-DRG 3632
|
| Min. Negotiated Rate |
$13,651.00 |
| Max. Negotiated Rate |
$58,721.47 |
| Rate for Payer: Affinity Essential Plan 1&2 |
$58,721.47
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$58,721.47
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$26,098.43
|
| Rate for Payer: Amida Care Medicaid |
$26,098.43
|
| Rate for Payer: EmblemHealth Essential Plan 1&2 |
$58,721.47
|
| Rate for Payer: EmblemHealth Essential Plan 3&4 |
$26,098.43
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$26,098.43
|
| Rate for Payer: Fidelis Qualified Health Plan |
$31,318.12
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$26,098.43
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$26,098.43
|
| Rate for Payer: Healthfirst Commercial |
$24,912.00
|
| Rate for Payer: Healthfirst Essential Plan |
$58,721.47
|
| Rate for Payer: Healthfirst QHP |
$13,651.00
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$26,098.43
|
| Rate for Payer: SOMOS Essential |
$58,721.47
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$58,721.47
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$58,721.47
|
| Rate for Payer: United Healthcare Medicaid |
$26,098.43
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$26,098.43
|
|
|
BRENTUXIMAB VEDOTIN 50 MG IV SOLR
|
Facility
|
OP
|
$13.00
|
|
|
Service Code
|
HCPCS J9042
|
| Hospital Charge Code |
5114405001
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$7.15 |
| Max. Negotiated Rate |
$263.81 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$7.15
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$258.64
|
| Rate for Payer: Aetna Government |
$258.64
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$181.05
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$181.05
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$181.05
|
| Rate for Payer: Brighton Health Commercial |
$9.75
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$258.64
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$10.40
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$8.84
|
| Rate for Payer: Elderplan Medicare Advantage |
$258.64
|
| Rate for Payer: EmblemHealth Commercial |
$258.64
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$232.78
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$219.84
|
| Rate for Payer: Fidelis Essential Plan QHP |
$230.19
|
| Rate for Payer: Fidelis Medicare Advantage |
$258.64
|
| Rate for Payer: Fidelis Qualified Health Plan |
$230.19
|
| Rate for Payer: Group Health Inc Commercial |
$258.64
|
| Rate for Payer: Group Health Inc Medicare |
$258.64
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$258.64
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$258.64
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$258.64
|
| Rate for Payer: Healthfirst Medicare Advantage |
$219.84
|
| Rate for Payer: Healthfirst QHP |
$258.64
|
| Rate for Payer: Humana Medicare |
$263.81
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$258.64
|
| Rate for Payer: United Healthcare Medicare Advantage |
$258.64
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$8.45
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$245.71
|
| Rate for Payer: Wellcare Medicare |
$245.71
|
|
|
BRENTUXIMAB VEDOTIN 50 MG IV SOLR
|
Facility
|
IP
|
$13.00
|
|
|
Service Code
|
HCPCS J9042
|
| Hospital Charge Code |
5114405001
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$6.50 |
| Max. Negotiated Rate |
$6.50 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$6.50
|
|
|
BRIMONIDINE TARTRATE 0.2 % OP SOLN
|
Facility
|
IP
|
$6.53
|
|
|
Service Code
|
NDC 6131414315
|
| Hospital Charge Code |
6131414315
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.26 |
| Max. Negotiated Rate |
$3.26 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$3.26
|
|
|
BRIMONIDINE TARTRATE 0.2 % OP SOLN
|
Facility
|
IP
|
$6.53
|
|
|
Service Code
|
NDC 6131414305
|
| Hospital Charge Code |
6131414305
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.27 |
| Max. Negotiated Rate |
$3.27 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$3.27
|
|
|
BRIMONIDINE TARTRATE 0.2 % OP SOLN
|
Facility
|
OP
|
$3.63
|
|
|
Service Code
|
NDC 2420841105
|
| Hospital Charge Code |
2420841105
|
|
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: EmblemHealth Commercial |
$1.81
|
| 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
|
Facility
|
OP
|
$2.50
|
|
|
Service Code
|
NDC 7006923101
|
| Hospital Charge Code |
7006923101
|
|
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: EmblemHealth Commercial |
$1.25
|
| 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
|
Facility
|
OP
|
$6.53
|
|
|
Service Code
|
NDC 6131414315
|
| Hospital Charge Code |
6131414315
|
|
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: EmblemHealth Commercial |
$3.26
|
| 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
|
Facility
|
IP
|
$3.63
|
|
|
Service Code
|
NDC 2420841105
|
| Hospital Charge Code |
2420841105
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.81 |
| Max. Negotiated Rate |
$1.81 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.81
|
|
|
BRIMONIDINE TARTRATE 0.2 % OP SOLN
|
Facility
|
IP
|
$0.75
|
|
|
Service Code
|
NDC 7006923301
|
| Hospital Charge Code |
7006923301
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$0.37 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.37
|
|
|
BRIMONIDINE TARTRATE 0.2 % OP SOLN
|
Facility
|
IP
|
$2.50
|
|
|
Service Code
|
NDC 7006923101
|
| Hospital Charge Code |
7006923101
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.25 |
| Max. Negotiated Rate |
$1.25 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.25
|
|
|
BRIMONIDINE TARTRATE 0.2 % OP SOLN
|
Facility
|
OP
|
$6.53
|
|
|
Service Code
|
NDC 6131414305
|
| Hospital Charge Code |
6131414305
|
|
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 |
$3.27
|
| Rate for Payer: Aetna Government |
$3.27
|
| 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: EmblemHealth Commercial |
$3.27
|
| Rate for Payer: Group Health Inc Commercial |
$3.27
|
| Rate for Payer: Group Health Inc Medicare |
$2.29
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$3.27
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$3.27
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$4.24
|
|
|
BRIMONIDINE TARTRATE 0.2 % OP SOLN
|
Facility
|
OP
|
$0.75
|
|
|
Service Code
|
NDC 7006923301
|
| Hospital Charge Code |
7006923301
|
|
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: EmblemHealth Commercial |
$0.37
|
| 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
|
|
