|
DACARBAZINE 200 MG IV SOLR [2091]
|
Facility
|
IP
|
$19.69
|
|
|
Service Code
|
HCPCS J9130
|
| Hospital Charge Code |
00703507501
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9.84 |
| Max. Negotiated Rate |
$9.84 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$9.84
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$9.84
|
|
|
DACARBAZINE 200 MG IV SOLR [2091]
|
Facility
|
OP
|
$19.69
|
|
|
Service Code
|
HCPCS J9130
|
| Hospital Charge Code |
00703507501
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3.71 |
| Max. Negotiated Rate |
$20.67 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$10.83
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3.71
|
| Rate for Payer: Aetna Government |
$3.71
|
| Rate for Payer: Brighton Health Commercial |
$11.81
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$9.84
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$11.32
|
| Rate for Payer: EmblemHealth Commercial |
$9.84
|
| Rate for Payer: Fidelis Medicare Advantage |
$20.67
|
| Rate for Payer: Group Health Inc Commercial |
$9.84
|
| Rate for Payer: Group Health Inc Medicare |
$6.89
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$9.84
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$9.84
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$12.80
|
|
|
DACARBAZINE 200 MG IV SOLR [2091]
|
Facility
|
IP
|
$14.40
|
|
|
Service Code
|
HCPCS J9130
|
| Hospital Charge Code |
63323012820
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7.20 |
| Max. Negotiated Rate |
$7.20 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$7.20
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$7.20
|
|
|
DACARBAZINE 200 MG IV SOLR [2091]
|
Facility
|
IP
|
$14.40
|
|
|
Service Code
|
HCPCS J9130
|
| Hospital Charge Code |
00143924510
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7.20 |
| Max. Negotiated Rate |
$7.20 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$7.20
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$7.20
|
|
|
DACARBAZINE 200 MG IV SOLR [2091]
|
Facility
|
OP
|
$14.40
|
|
|
Service Code
|
HCPCS J9130
|
| Hospital Charge Code |
63323012820
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3.71 |
| Max. Negotiated Rate |
$15.12 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$7.92
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3.71
|
| Rate for Payer: Aetna Government |
$3.71
|
| Rate for Payer: Brighton Health Commercial |
$8.64
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$7.20
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$8.28
|
| Rate for Payer: EmblemHealth Commercial |
$7.20
|
| Rate for Payer: Fidelis Medicare Advantage |
$15.12
|
| Rate for Payer: Group Health Inc Commercial |
$7.20
|
| Rate for Payer: Group Health Inc Medicare |
$5.04
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$7.20
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$7.20
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$9.36
|
|
|
DACARBRAZINE 100 MG INJ
|
Facility
|
IP
|
$5.17
|
|
|
Service Code
|
HCPCS J9130
|
| Hospital Charge Code |
41642884
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.58 |
| Max. Negotiated Rate |
$2.58 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.58
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2.58
|
|
|
DACARBRAZINE 100 MG INJ
|
Facility
|
OP
|
$5.17
|
|
|
Service Code
|
HCPCS J9130
|
| Hospital Charge Code |
41642884
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.81 |
| Max. Negotiated Rate |
$3.91 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2.84
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3.71
|
| Rate for Payer: Aetna Government |
$3.71
|
| Rate for Payer: Brighton Health Commercial |
$3.10
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2.58
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2.97
|
| Rate for Payer: Group Health Inc Commercial |
$2.58
|
| Rate for Payer: Group Health Inc Medicare |
$1.81
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.58
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2.58
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$3.91
|
| Rate for Payer: SOMOS Essential |
$3.91
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3.36
|
|
|
DACTINOMYCIN 500 MCG INJ - NF
|
Facility
|
OP
|
$955.00
|
|
|
Service Code
|
HCPCS J9120
|
| Hospital Charge Code |
41654394
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$468.23 |
| Max. Negotiated Rate |
$702.35 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$525.25
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$668.90
|
| Rate for Payer: Aetna Government |
$668.90
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$468.23
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$468.23
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$468.23
|
| Rate for Payer: Brighton Health Commercial |
$573.00
|
| Rate for Payer: Cash Price |
$668.90
|
| Rate for Payer: Cash Price |
$668.90
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$668.90
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$477.50
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$549.12
|
| Rate for Payer: Elderplan Medicare Advantage |
$668.90
|
| Rate for Payer: EmblemHealth Commercial |
$668.90
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$668.90
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$668.90
|
| Rate for Payer: Fidelis Essential Plan QHP |
$702.35
|
| Rate for Payer: Fidelis Medicare Advantage |
$668.90
|
| Rate for Payer: Fidelis Qualified Health Plan |
$702.35
|
| Rate for Payer: Group Health Inc Commercial |
$668.90
|
| Rate for Payer: Group Health Inc Medicare |
$668.90
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$477.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$477.50
|
| Rate for Payer: Healthfirst Medicare Advantage |
$568.57
|
| Rate for Payer: Healthfirst QHP |
$668.90
|
| Rate for Payer: Humana Medicare |
$682.28
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$668.90
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$580.66
|
| Rate for Payer: SOMOS Essential |
$580.66
|
| Rate for Payer: United Healthcare Commercial |
$604.79
|
| Rate for Payer: United Healthcare Medicare Advantage |
$668.90
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$620.75
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$535.12
|
| Rate for Payer: Wellcare Medicare |
$635.46
|
|
|
DACTINOMYCIN 500 MCG INJ - NF
|
Facility
|
IP
|
$955.00
|
|
|
Service Code
|
HCPCS J9120
|
| Hospital Charge Code |
41654394
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$477.50 |
| Max. Negotiated Rate |
$477.50 |
| Rate for Payer: Cash Price |
$668.90
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$477.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$477.50
|
|
|
DACTINOMYCIN 500 MCG INJ - NF
|
Facility
|
IP
|
$955.00
|
|
|
Service Code
|
HCPCS J9120
|
| Hospital Charge Code |
41644394
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$477.50 |
| Max. Negotiated Rate |
$477.50 |
| Rate for Payer: Cash Price |
$668.90
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$477.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$477.50
|
|
|
DACTINOMYCIN 500 MCG INJ - NF
|
Facility
|
OP
|
$955.00
|
|
|
Service Code
|
HCPCS J9120
|
| Hospital Charge Code |
41644394
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$468.23 |
| Max. Negotiated Rate |
$702.35 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$525.25
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$668.90
|
| Rate for Payer: Aetna Government |
$668.90
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$468.23
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$468.23
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$468.23
|
| Rate for Payer: Brighton Health Commercial |
$573.00
|
| Rate for Payer: Cash Price |
$668.90
|
| Rate for Payer: Cash Price |
$668.90
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$668.90
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$477.50
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$549.12
|
| Rate for Payer: Elderplan Medicare Advantage |
$668.90
|
| Rate for Payer: EmblemHealth Commercial |
$668.90
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$668.90
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$668.90
|
| Rate for Payer: Fidelis Essential Plan QHP |
$702.35
|
| Rate for Payer: Fidelis Medicare Advantage |
$668.90
|
| Rate for Payer: Fidelis Qualified Health Plan |
$702.35
|
| Rate for Payer: Group Health Inc Commercial |
$668.90
|
| Rate for Payer: Group Health Inc Medicare |
$668.90
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$477.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$477.50
|
| Rate for Payer: Healthfirst Medicare Advantage |
$568.57
|
| Rate for Payer: Healthfirst QHP |
$668.90
|
| Rate for Payer: Humana Medicare |
$682.28
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$668.90
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$580.66
|
| Rate for Payer: SOMOS Essential |
$580.66
|
| Rate for Payer: United Healthcare Commercial |
$604.79
|
| Rate for Payer: United Healthcare Medicare Advantage |
$668.90
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$620.75
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$535.12
|
| Rate for Payer: Wellcare Medicare |
$635.46
|
|
|
DAKINS (1/2 STRENGTH) 0.25 % EX SOLN [15950]
|
Facility
|
OP
|
$0.04
|
|
|
Service Code
|
NDC 39328006325
|
| Hospital Charge Code |
39328006325
|
|
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 |
$0.03
|
| 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
|
|
|
DAKINS (1/2 STRENGTH) 0.25 % EX SOLN [15950]
|
Facility
|
OP
|
$0.03
|
|
|
Service Code
|
NDC 00436093616
|
| Hospital Charge Code |
00436093616
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.02
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.01
|
| Rate for Payer: Aetna Government |
$0.01
|
| Rate for Payer: Brighton Health Commercial |
$0.02
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.02
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.02
|
| Rate for Payer: Group Health Inc Commercial |
$0.01
|
| Rate for Payer: Group Health Inc Medicare |
$0.01
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.01
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.01
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.02
|
|
|
DAKINS (1/4 STRENGTH) 0.125 % EX SOLN [76724]
|
Facility
|
OP
|
$0.03
|
|
|
Service Code
|
NDC 00436067216
|
| Hospital Charge Code |
00436067216
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.02
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.01
|
| Rate for Payer: Aetna Government |
$0.01
|
| Rate for Payer: Brighton Health Commercial |
$0.02
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.02
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.02
|
| Rate for Payer: Group Health Inc Commercial |
$0.01
|
| Rate for Payer: Group Health Inc Medicare |
$0.01
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.01
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.01
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.02
|
|
|
DAKINS (1/4 STRENGTH) 0.125 % EX SOLN [76724]
|
Facility
|
OP
|
$0.04
|
|
|
Service Code
|
NDC 39328006412
|
| Hospital Charge Code |
39328006412
|
|
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 |
$0.03
|
| 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
|
|
|
DALBAVANCIN HCL 500 MG IV SOLR [126244]
|
Facility
|
OP
|
$2,134.96
|
|
|
Service Code
|
HCPCS J0875
|
| Hospital Charge Code |
57970010001
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$12.23 |
| Max. Negotiated Rate |
$1,387.72 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,174.23
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$15.29
|
| Rate for Payer: Aetna Government |
$15.29
|
| Rate for Payer: Brighton Health Commercial |
$1,280.98
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$15.29
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,067.48
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,227.60
|
| Rate for Payer: Elderplan Medicare Advantage |
$15.29
|
| Rate for Payer: EmblemHealth Commercial |
$1,067.48
|
| Rate for Payer: Fidelis Medicare Advantage |
$15.29
|
| Rate for Payer: Group Health Inc Commercial |
$15.29
|
| Rate for Payer: Group Health Inc Medicare |
$15.29
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,067.48
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,067.48
|
| Rate for Payer: Healthfirst Medicare Advantage |
$13.00
|
| Rate for Payer: Healthfirst QHP |
$15.29
|
| Rate for Payer: Humana Medicare |
$15.60
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$15.29
|
| Rate for Payer: United Healthcare Medicare Advantage |
$15.29
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,387.72
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$12.23
|
|
|
DALBAVANCIN HCL 500 MG IV SOLR [126244]
|
Facility
|
IP
|
$2,134.96
|
|
|
Service Code
|
HCPCS J0875
|
| Hospital Charge Code |
57970010001
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,067.48 |
| Max. Negotiated Rate |
$1,067.48 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,067.48
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,067.48
|
|
|
DALBAVANCIN POWDER 5MG
|
Facility
|
OP
|
$19.54
|
|
|
Service Code
|
HCPCS J0875
|
| Hospital Charge Code |
41640323
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.77 |
| Max. Negotiated Rate |
$16.06 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$10.75
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$15.29
|
| Rate for Payer: Aetna Government |
$15.29
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$10.71
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$10.71
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$10.71
|
| Rate for Payer: Brighton Health Commercial |
$11.72
|
| Rate for Payer: Cash Price |
$15.29
|
| Rate for Payer: Cash Price |
$15.29
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$15.29
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$9.77
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$11.24
|
| Rate for Payer: Elderplan Medicare Advantage |
$15.29
|
| Rate for Payer: EmblemHealth Commercial |
$15.29
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$15.29
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$15.29
|
| Rate for Payer: Fidelis Essential Plan QHP |
$16.06
|
| Rate for Payer: Fidelis Medicare Advantage |
$15.29
|
| Rate for Payer: Fidelis Qualified Health Plan |
$16.06
|
| Rate for Payer: Group Health Inc Commercial |
$15.29
|
| Rate for Payer: Group Health Inc Medicare |
$15.29
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$9.77
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$9.77
|
| Rate for Payer: Healthfirst Medicare Advantage |
$13.00
|
| Rate for Payer: Healthfirst QHP |
$15.29
|
| Rate for Payer: Humana Medicare |
$15.60
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$15.29
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$16.03
|
| Rate for Payer: SOMOS Essential |
$16.03
|
| Rate for Payer: United Healthcare Commercial |
$14.91
|
| Rate for Payer: United Healthcare Medicare Advantage |
$15.29
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$12.70
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$12.23
|
| Rate for Payer: Wellcare Medicare |
$14.53
|
|
|
DALBAVANCIN POWDER 5MG
|
Facility
|
IP
|
$19.54
|
|
|
Service Code
|
HCPCS J0875
|
| Hospital Charge Code |
41650323
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.77 |
| Max. Negotiated Rate |
$9.77 |
| Rate for Payer: Cash Price |
$15.29
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$9.77
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$9.77
|
|
|
DALBAVANCIN POWDER 5MG
|
Facility
|
IP
|
$19.54
|
|
|
Service Code
|
HCPCS J0875
|
| Hospital Charge Code |
41640323
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.77 |
| Max. Negotiated Rate |
$9.77 |
| Rate for Payer: Cash Price |
$15.29
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$9.77
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$9.77
|
|
|
DALBAVANCIN POWDER 5MG
|
Facility
|
OP
|
$19.54
|
|
|
Service Code
|
HCPCS J0875
|
| Hospital Charge Code |
41650323
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.77 |
| Max. Negotiated Rate |
$16.06 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$10.75
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$15.29
|
| Rate for Payer: Aetna Government |
$15.29
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$10.71
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$10.71
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$10.71
|
| Rate for Payer: Brighton Health Commercial |
$11.72
|
| Rate for Payer: Cash Price |
$15.29
|
| Rate for Payer: Cash Price |
$15.29
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$15.29
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$9.77
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$11.24
|
| Rate for Payer: Elderplan Medicare Advantage |
$15.29
|
| Rate for Payer: EmblemHealth Commercial |
$15.29
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$15.29
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$15.29
|
| Rate for Payer: Fidelis Essential Plan QHP |
$16.06
|
| Rate for Payer: Fidelis Medicare Advantage |
$15.29
|
| Rate for Payer: Fidelis Qualified Health Plan |
$16.06
|
| Rate for Payer: Group Health Inc Commercial |
$15.29
|
| Rate for Payer: Group Health Inc Medicare |
$15.29
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$9.77
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$9.77
|
| Rate for Payer: Healthfirst Medicare Advantage |
$13.00
|
| Rate for Payer: Healthfirst QHP |
$15.29
|
| Rate for Payer: Humana Medicare |
$15.60
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$15.29
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$16.03
|
| Rate for Payer: SOMOS Essential |
$16.03
|
| Rate for Payer: United Healthcare Commercial |
$14.91
|
| Rate for Payer: United Healthcare Medicare Advantage |
$15.29
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$12.70
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$12.23
|
| Rate for Payer: Wellcare Medicare |
$14.53
|
|
|
DALFOPRISTIN + QUINUPRISTIN 500 MG INJ
|
Facility
|
IP
|
$340.05
|
|
|
Service Code
|
HCPCS J2770
|
| Hospital Charge Code |
41653096
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$170.02 |
| Max. Negotiated Rate |
$170.02 |
| Rate for Payer: Cash Price |
$493.97
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$170.02
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$170.02
|
|
|
DALFOPRISTIN + QUINUPRISTIN 500 MG INJ
|
Facility
|
OP
|
$340.05
|
|
|
Service Code
|
HCPCS J2770
|
| Hospital Charge Code |
41653096
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$170.02 |
| Max. Negotiated Rate |
$518.67 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$187.03
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$493.97
|
| Rate for Payer: Aetna Government |
$493.97
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$345.78
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$345.78
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$345.78
|
| Rate for Payer: Brighton Health Commercial |
$204.03
|
| Rate for Payer: Cash Price |
$493.97
|
| Rate for Payer: Cash Price |
$493.97
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$493.97
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$170.02
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$195.53
|
| Rate for Payer: Elderplan Medicare Advantage |
$493.97
|
| Rate for Payer: EmblemHealth Commercial |
$493.97
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$493.97
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$493.97
|
| Rate for Payer: Fidelis Essential Plan QHP |
$518.67
|
| Rate for Payer: Fidelis Medicare Advantage |
$493.97
|
| Rate for Payer: Fidelis Qualified Health Plan |
$518.67
|
| Rate for Payer: Group Health Inc Commercial |
$493.97
|
| Rate for Payer: Group Health Inc Medicare |
$493.97
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$170.02
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$170.02
|
| Rate for Payer: Healthfirst Medicare Advantage |
$419.87
|
| Rate for Payer: Healthfirst QHP |
$493.97
|
| Rate for Payer: Humana Medicare |
$503.85
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$493.97
|
| Rate for Payer: United Healthcare Commercial |
$493.97
|
| Rate for Payer: United Healthcare Medicare Advantage |
$493.97
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$221.03
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$395.18
|
| Rate for Payer: Wellcare Medicare |
$469.27
|
|
|
DALFOPRISTIN + QUINUPRISTIN 500 MG INJ
|
Facility
|
IP
|
$340.05
|
|
|
Service Code
|
HCPCS J2770
|
| Hospital Charge Code |
41643096
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$170.02 |
| Max. Negotiated Rate |
$170.02 |
| Rate for Payer: Cash Price |
$493.97
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$170.02
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$170.02
|
|
|
DALFOPRISTIN + QUINUPRISTIN 500 MG INJ
|
Facility
|
OP
|
$340.05
|
|
|
Service Code
|
HCPCS J2770
|
| Hospital Charge Code |
41643096
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$170.02 |
| Max. Negotiated Rate |
$518.67 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$187.03
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$493.97
|
| Rate for Payer: Aetna Government |
$493.97
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$345.78
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$345.78
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$345.78
|
| Rate for Payer: Brighton Health Commercial |
$204.03
|
| Rate for Payer: Cash Price |
$493.97
|
| Rate for Payer: Cash Price |
$493.97
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$493.97
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$170.02
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$195.53
|
| Rate for Payer: Elderplan Medicare Advantage |
$493.97
|
| Rate for Payer: EmblemHealth Commercial |
$493.97
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$493.97
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$493.97
|
| Rate for Payer: Fidelis Essential Plan QHP |
$518.67
|
| Rate for Payer: Fidelis Medicare Advantage |
$493.97
|
| Rate for Payer: Fidelis Qualified Health Plan |
$518.67
|
| Rate for Payer: Group Health Inc Commercial |
$493.97
|
| Rate for Payer: Group Health Inc Medicare |
$493.97
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$170.02
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$170.02
|
| Rate for Payer: Healthfirst Medicare Advantage |
$419.87
|
| Rate for Payer: Healthfirst QHP |
$493.97
|
| Rate for Payer: Humana Medicare |
$503.85
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$493.97
|
| Rate for Payer: United Healthcare Commercial |
$493.97
|
| Rate for Payer: United Healthcare Medicare Advantage |
$493.97
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$221.03
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$395.18
|
| Rate for Payer: Wellcare Medicare |
$469.27
|
|
