|
CYCLOPENTOLATE-PHENYLEPHRINE 0.2-1 % OP SOLN [9701]
|
Facility
|
OP
|
$21.16
|
|
|
Service Code
|
NDC 00065035902
|
| Hospital Charge Code |
00065035902
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.40 |
| Max. Negotiated Rate |
$16.92 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$11.64
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$10.58
|
| Rate for Payer: Aetna Government |
$10.58
|
| Rate for Payer: Brighton Health Commercial |
$15.87
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$16.92
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$14.39
|
| Rate for Payer: Group Health Inc Commercial |
$10.58
|
| Rate for Payer: Group Health Inc Medicare |
$7.40
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$10.58
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$10.58
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$13.75
|
|
|
CYCLOPHOSPHAMIDE 1000 MG INJ
|
Facility
|
OP
|
$661.05
|
|
|
Service Code
|
HCPCS J9070
|
| Hospital Charge Code |
41653750
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.11 |
| Max. Negotiated Rate |
$429.68 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$363.58
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$20.15
|
| Rate for Payer: Aetna Government |
$20.15
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$14.11
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$14.11
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$14.11
|
| Rate for Payer: Brighton Health Commercial |
$396.63
|
| 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 |
$330.52
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$380.10
|
| Rate for Payer: Elderplan Medicare Advantage |
$20.15
|
| Rate for Payer: EmblemHealth Commercial |
$20.15
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$20.15
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$20.15
|
| Rate for Payer: Fidelis Essential Plan QHP |
$21.16
|
| Rate for Payer: Fidelis Medicare Advantage |
$20.15
|
| Rate for Payer: Fidelis Qualified Health Plan |
$21.16
|
| 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 |
$330.52
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$330.52
|
| Rate for Payer: Healthfirst Medicare Advantage |
$17.13
|
| Rate for Payer: Healthfirst QHP |
$20.15
|
| Rate for Payer: Humana Medicare |
$20.56
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$20.15
|
| Rate for Payer: United Healthcare Commercial |
$22.13
|
| Rate for Payer: United Healthcare Medicare Advantage |
$20.15
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$429.68
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$16.12
|
| Rate for Payer: Wellcare Medicare |
$19.15
|
|
|
CYCLOPHOSPHAMIDE 1000 MG INJ
|
Facility
|
IP
|
$661.05
|
|
|
Service Code
|
HCPCS J9070
|
| Hospital Charge Code |
41653750
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$330.52 |
| Max. Negotiated Rate |
$330.52 |
| Rate for Payer: Cash Price |
$20.15
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$330.52
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$330.52
|
|
|
CYCLOPHOSPHAMIDE 1000 MG INJ
|
Facility
|
OP
|
$661.05
|
|
| Hospital Charge Code |
41643750
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$231.37 |
| Max. Negotiated Rate |
$528.84 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$363.58
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$330.52
|
| Rate for Payer: Aetna Government |
$330.52
|
| Rate for Payer: Brighton Health Commercial |
$495.79
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$528.84
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$449.51
|
| Rate for Payer: Group Health Inc Commercial |
$330.52
|
| Rate for Payer: Group Health Inc Medicare |
$231.37
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$330.52
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$330.52
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$429.68
|
|
|
CYCLOPHOSPHAMIDE 1 G IJ SOLR [38270]
|
Facility
|
OP
|
$824.06
|
|
|
Service Code
|
HCPCS J9075
|
| Hospital Charge Code |
00781324494
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.92 |
| Max. Negotiated Rate |
$659.25 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$453.23
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$412.03
|
| Rate for Payer: Aetna Government |
$412.03
|
| Rate for Payer: Brighton Health Commercial |
$618.04
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$659.25
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$560.36
|
| Rate for Payer: Group Health Inc Commercial |
$412.03
|
| Rate for Payer: Group Health Inc Medicare |
$288.42
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$412.03
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$412.03
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$0.92
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$0.97
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$0.97
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$0.97
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$535.64
|
|
|
CYCLOPHOSPHAMIDE 1 G IJ SOLR [38270]
|
Facility
|
OP
|
$879.00
|
|
|
Service Code
|
HCPCS J9075
|
| Hospital Charge Code |
10019095601
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.92 |
| Max. Negotiated Rate |
$703.20 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$483.45
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$439.50
|
| Rate for Payer: Aetna Government |
$439.50
|
| Rate for Payer: Brighton Health Commercial |
$659.25
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$703.20
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$597.72
|
| Rate for Payer: Group Health Inc Commercial |
$439.50
|
| Rate for Payer: Group Health Inc Medicare |
$307.65
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$439.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$439.50
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$0.92
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$0.97
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$0.97
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$0.97
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$571.35
|
|
|
CYCLOPHOSPHAMIDE 1 G IJ SOLR [38270]
|
Facility
|
OP
|
$791.10
|
|
|
Service Code
|
HCPCS J9075
|
| Hospital Charge Code |
70121123901
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.92 |
| Max. Negotiated Rate |
$632.88 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$435.10
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$395.55
|
| Rate for Payer: Aetna Government |
$395.55
|
| Rate for Payer: Brighton Health Commercial |
$593.32
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$632.88
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$537.95
|
| Rate for Payer: Group Health Inc Commercial |
$395.55
|
| Rate for Payer: Group Health Inc Medicare |
$276.88
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$395.55
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$395.55
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$0.92
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$0.97
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$0.97
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$0.97
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$514.22
|
|
|
CYCLOPHOSPHAMIDE 1 GM/5ML IV SOLN [174601]
|
Facility
|
IP
|
$175.80
|
|
|
Service Code
|
HCPCS J9075
|
| Hospital Charge Code |
50742052005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$87.90 |
| Max. Negotiated Rate |
$87.90 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$87.90
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$87.90
|
|
|
CYCLOPHOSPHAMIDE 1 GM/5ML IV SOLN [174601]
|
Facility
|
OP
|
$175.80
|
|
|
Service Code
|
HCPCS J9075
|
| Hospital Charge Code |
50742052005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$61.53 |
| Max. Negotiated Rate |
$184.59 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$96.69
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$87.90
|
| Rate for Payer: Aetna Government |
$87.90
|
| Rate for Payer: Brighton Health Commercial |
$105.48
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$87.90
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$101.08
|
| Rate for Payer: EmblemHealth Commercial |
$87.90
|
| Rate for Payer: Fidelis Medicare Advantage |
$184.59
|
| Rate for Payer: Group Health Inc Commercial |
$87.90
|
| Rate for Payer: Group Health Inc Medicare |
$61.53
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$87.90
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$87.90
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$114.27
|
|
|
CYCLOPHOSPHAMIDE 2000 MG INJ
|
Facility
|
OP
|
$159.00
|
|
|
Service Code
|
HCPCS J9070
|
| Hospital Charge Code |
41643828
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.11 |
| Max. Negotiated Rate |
$103.35 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$87.45
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$20.15
|
| Rate for Payer: Aetna Government |
$20.15
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$14.11
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$14.11
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$14.11
|
| Rate for Payer: Brighton Health Commercial |
$95.40
|
| 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 |
$79.50
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$91.42
|
| Rate for Payer: Elderplan Medicare Advantage |
$20.15
|
| Rate for Payer: EmblemHealth Commercial |
$20.15
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$20.15
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$20.15
|
| Rate for Payer: Fidelis Essential Plan QHP |
$21.16
|
| Rate for Payer: Fidelis Medicare Advantage |
$20.15
|
| Rate for Payer: Fidelis Qualified Health Plan |
$21.16
|
| 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 |
$79.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$79.50
|
| Rate for Payer: Healthfirst Medicare Advantage |
$17.13
|
| Rate for Payer: Healthfirst QHP |
$20.15
|
| Rate for Payer: Humana Medicare |
$20.56
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$20.15
|
| Rate for Payer: United Healthcare Commercial |
$22.13
|
| Rate for Payer: United Healthcare Medicare Advantage |
$20.15
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$103.35
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$16.12
|
| Rate for Payer: Wellcare Medicare |
$19.15
|
|
|
CYCLOPHOSPHAMIDE 2000 MG INJ
|
Facility
|
IP
|
$159.00
|
|
|
Service Code
|
HCPCS J9070
|
| Hospital Charge Code |
41643828
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$79.50 |
| Max. Negotiated Rate |
$79.50 |
| Rate for Payer: Cash Price |
$20.15
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$79.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$79.50
|
|
|
CYCLOPHOSPHAMIDE 2000 MG INJ
|
Facility
|
OP
|
$159.00
|
|
|
Service Code
|
HCPCS J9070
|
| Hospital Charge Code |
41653828
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.11 |
| Max. Negotiated Rate |
$103.35 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$87.45
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$20.15
|
| Rate for Payer: Aetna Government |
$20.15
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$14.11
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$14.11
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$14.11
|
| Rate for Payer: Brighton Health Commercial |
$95.40
|
| 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 |
$79.50
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$91.42
|
| Rate for Payer: Elderplan Medicare Advantage |
$20.15
|
| Rate for Payer: EmblemHealth Commercial |
$20.15
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$20.15
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$20.15
|
| Rate for Payer: Fidelis Essential Plan QHP |
$21.16
|
| Rate for Payer: Fidelis Medicare Advantage |
$20.15
|
| Rate for Payer: Fidelis Qualified Health Plan |
$21.16
|
| 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 |
$79.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$79.50
|
| Rate for Payer: Healthfirst Medicare Advantage |
$17.13
|
| Rate for Payer: Healthfirst QHP |
$20.15
|
| Rate for Payer: Humana Medicare |
$20.56
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$20.15
|
| Rate for Payer: United Healthcare Commercial |
$22.13
|
| Rate for Payer: United Healthcare Medicare Advantage |
$20.15
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$103.35
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$16.12
|
| Rate for Payer: Wellcare Medicare |
$19.15
|
|
|
CYCLOPHOSPHAMIDE 2000 MG INJ
|
Facility
|
IP
|
$159.00
|
|
|
Service Code
|
HCPCS J9070
|
| Hospital Charge Code |
41653828
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$79.50 |
| Max. Negotiated Rate |
$79.50 |
| Rate for Payer: Cash Price |
$20.15
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$79.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$79.50
|
|
|
CYCLOPHOSPHAMIDE 25 MG PO CAPS [126404]
|
Facility
|
OP
|
$9.36
|
|
|
Service Code
|
HCPCS J8530
|
| Hospital Charge Code |
00054038225
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.81 |
| Max. Negotiated Rate |
$7.49 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$5.15
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.81
|
| Rate for Payer: Aetna Government |
$0.81
|
| Rate for Payer: Brighton Health Commercial |
$7.02
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$7.49
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$6.37
|
| Rate for Payer: Group Health Inc Commercial |
$4.68
|
| Rate for Payer: Group Health Inc Medicare |
$3.28
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4.68
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4.68
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$0.86
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$0.91
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$0.91
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$0.91
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$6.09
|
|
|
CYCLOPHOSPHAMIDE 25 MG TAB
|
Facility
|
IP
|
$2.45
|
|
|
Service Code
|
HCPCS J8530
|
| Hospital Charge Code |
41651183
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.22 |
| Max. Negotiated Rate |
$1.22 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.22
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.22
|
|
|
CYCLOPHOSPHAMIDE 25 MG TAB
|
Facility
|
OP
|
$2.45
|
|
|
Service Code
|
HCPCS J8530
|
| Hospital Charge Code |
41641183
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.81 |
| Max. Negotiated Rate |
$1.59 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.35
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.81
|
| Rate for Payer: Aetna Government |
$0.81
|
| Rate for Payer: Brighton Health Commercial |
$1.47
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.22
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.41
|
| Rate for Payer: Group Health Inc Commercial |
$1.22
|
| Rate for Payer: Group Health Inc Medicare |
$0.86
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.22
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.22
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$0.91
|
| Rate for Payer: SOMOS Essential |
$0.91
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.59
|
|
|
CYCLOPHOSPHAMIDE 25 MG TAB
|
Facility
|
IP
|
$2.45
|
|
|
Service Code
|
HCPCS J8530
|
| Hospital Charge Code |
41641183
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.22 |
| Max. Negotiated Rate |
$1.22 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.22
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.22
|
|
|
CYCLOPHOSPHAMIDE 25 MG TAB
|
Facility
|
OP
|
$2.45
|
|
|
Service Code
|
HCPCS J8530
|
| Hospital Charge Code |
41651183
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.81 |
| Max. Negotiated Rate |
$1.59 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.35
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.81
|
| Rate for Payer: Aetna Government |
$0.81
|
| Rate for Payer: Brighton Health Commercial |
$1.47
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.22
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.41
|
| Rate for Payer: Group Health Inc Commercial |
$1.22
|
| Rate for Payer: Group Health Inc Medicare |
$0.86
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.22
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.22
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$0.91
|
| Rate for Payer: SOMOS Essential |
$0.91
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.59
|
|
|
CYCLOPHOSPHAMIDE 2 G IJ SOLR [38280]
|
Facility
|
OP
|
$1,758.00
|
|
|
Service Code
|
HCPCS J9075
|
| Hospital Charge Code |
10019095701
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.92 |
| Max. Negotiated Rate |
$1,406.40 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$966.90
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$879.00
|
| Rate for Payer: Aetna Government |
$879.00
|
| Rate for Payer: Brighton Health Commercial |
$1,318.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,406.40
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,195.44
|
| Rate for Payer: Group Health Inc Commercial |
$879.00
|
| Rate for Payer: Group Health Inc Medicare |
$615.30
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$879.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$879.00
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$0.92
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$0.97
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$0.97
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$0.97
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,142.70
|
|
|
CYCLOPHOSPHAMIDE 2 GM/10ML IV SOLN [182682]
|
Facility
|
IP
|
$175.80
|
|
|
Service Code
|
HCPCS J9070
|
| Hospital Charge Code |
50742052110
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$87.90 |
| Max. Negotiated Rate |
$87.90 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$87.90
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$87.90
|
|
|
CYCLOPHOSPHAMIDE 2 GM/10ML IV SOLN [182682]
|
Facility
|
OP
|
$175.80
|
|
|
Service Code
|
HCPCS J9070
|
| Hospital Charge Code |
50742052110
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$16.12 |
| Max. Negotiated Rate |
$114.27 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$96.69
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$20.15
|
| Rate for Payer: Aetna Government |
$20.15
|
| Rate for Payer: Brighton Health Commercial |
$105.48
|
| 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 |
$87.90
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$101.08
|
| Rate for Payer: Elderplan Medicare Advantage |
$20.15
|
| Rate for Payer: EmblemHealth Commercial |
$87.90
|
| Rate for Payer: Fidelis Medicare Advantage |
$20.15
|
| 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 |
$87.90
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$87.90
|
| Rate for Payer: Healthfirst Medicare Advantage |
$17.13
|
| Rate for Payer: Healthfirst QHP |
$20.15
|
| Rate for Payer: Humana Medicare |
$20.56
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$20.15
|
| Rate for Payer: United Healthcare Medicare Advantage |
$20.15
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$114.27
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$16.12
|
|
|
CYCLOPHOSPHAMIDE 500 MG/2.5ML IV SOLN [174600]
|
Facility
|
OP
|
$175.80
|
|
|
Service Code
|
HCPCS J9075
|
| Hospital Charge Code |
50742051902
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$61.53 |
| Max. Negotiated Rate |
$184.59 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$96.69
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$87.90
|
| Rate for Payer: Aetna Government |
$87.90
|
| Rate for Payer: Brighton Health Commercial |
$105.48
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$87.90
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$101.08
|
| Rate for Payer: EmblemHealth Commercial |
$87.90
|
| Rate for Payer: Fidelis Medicare Advantage |
$184.59
|
| Rate for Payer: Group Health Inc Commercial |
$87.90
|
| Rate for Payer: Group Health Inc Medicare |
$61.53
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$87.90
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$87.90
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$114.27
|
|
|
CYCLOPHOSPHAMIDE 500 MG/2.5ML IV SOLN [174600]
|
Facility
|
IP
|
$175.80
|
|
|
Service Code
|
HCPCS J9075
|
| Hospital Charge Code |
50742051902
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$87.90 |
| Max. Negotiated Rate |
$87.90 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$87.90
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$87.90
|
|
|
CYCLOPHOSPHAMIDE 500 MG IJ SOLR [38271]
|
Facility
|
OP
|
$412.03
|
|
|
Service Code
|
HCPCS J9075
|
| Hospital Charge Code |
00781323394
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.92 |
| Max. Negotiated Rate |
$329.62 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$226.62
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$206.02
|
| Rate for Payer: Aetna Government |
$206.02
|
| Rate for Payer: Brighton Health Commercial |
$309.02
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$329.62
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$280.18
|
| Rate for Payer: Group Health Inc Commercial |
$206.02
|
| Rate for Payer: Group Health Inc Medicare |
$144.21
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$206.02
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$206.02
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$0.92
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$0.97
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$0.97
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$0.97
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$267.82
|
|
|
CYCLOPHOSPHAMIDE 500 MG IJ SOLR [38271]
|
Facility
|
OP
|
$439.50
|
|
|
Service Code
|
HCPCS J9075
|
| Hospital Charge Code |
10019095550
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.92 |
| Max. Negotiated Rate |
$351.60 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$241.72
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$219.75
|
| Rate for Payer: Aetna Government |
$219.75
|
| Rate for Payer: Brighton Health Commercial |
$329.62
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$351.60
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$298.86
|
| Rate for Payer: Group Health Inc Commercial |
$219.75
|
| Rate for Payer: Group Health Inc Medicare |
$153.82
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$219.75
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$219.75
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$0.92
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$0.97
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$0.97
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$0.97
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$285.68
|
|
