|
HC QUANTITATION DRUG NOT ELSEWHERE SPECIFIED - KANAMYCIN LEVEL
|
Facility
|
IP
|
$46.00
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
3018029916
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$23.00 |
| Max. Negotiated Rate |
$23.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$23.00
|
|
|
HC QUANTITATION DRUG NOT ELSEWHERE SPECIFIED - LAMOTRIGINE LEVEL
|
Facility
|
OP
|
$46.00
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
3018029908
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$13.05 |
| Max. Negotiated Rate |
$34.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$25.30
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$18.64
|
| Rate for Payer: Aetna Government |
$18.64
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$13.05
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$13.05
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$13.05
|
| Rate for Payer: Brighton Health Commercial |
$34.50
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$18.64
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$23.28
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$19.60
|
| Rate for Payer: Elderplan Medicare Advantage |
$18.64
|
| Rate for Payer: EmblemHealth Commercial |
$18.64
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$16.78
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$15.84
|
| Rate for Payer: Fidelis Essential Plan QHP |
$16.59
|
| Rate for Payer: Fidelis Medicare Advantage |
$18.64
|
| Rate for Payer: Fidelis Qualified Health Plan |
$16.59
|
| Rate for Payer: Group Health Inc Commercial |
$18.64
|
| Rate for Payer: Group Health Inc Medicare |
$18.64
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$18.64
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$18.64
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$18.64
|
| Rate for Payer: Healthfirst Medicare Advantage |
$18.64
|
| Rate for Payer: Healthfirst QHP |
$18.64
|
| Rate for Payer: Humana Medicare |
$19.01
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$18.64
|
| Rate for Payer: United Healthcare Commercial |
$17.34
|
| Rate for Payer: United Healthcare Medicare Advantage |
$18.64
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$18.64
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$17.71
|
| Rate for Payer: Wellcare Medicare |
$16.78
|
|
|
HC QUANTITATION DRUG NOT ELSEWHERE SPECIFIED - LAMOTRIGINE LEVEL
|
Facility
|
IP
|
$46.00
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
3018029908
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$23.00 |
| Max. Negotiated Rate |
$23.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$23.00
|
|
|
HC QUANTITATION DRUG NOT ELSEWHERE SPECIFIED - LEVETIRACETAM LEVEL
|
Facility
|
IP
|
$46.00
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
3018029909
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$23.00 |
| Max. Negotiated Rate |
$23.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$23.00
|
|
|
HC QUANTITATION DRUG NOT ELSEWHERE SPECIFIED - LEVETIRACETAM LEVEL
|
Facility
|
OP
|
$46.00
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
3018029909
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$13.05 |
| Max. Negotiated Rate |
$34.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$25.30
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$18.64
|
| Rate for Payer: Aetna Government |
$18.64
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$13.05
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$13.05
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$13.05
|
| Rate for Payer: Brighton Health Commercial |
$34.50
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$18.64
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$23.28
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$19.60
|
| Rate for Payer: Elderplan Medicare Advantage |
$18.64
|
| Rate for Payer: EmblemHealth Commercial |
$18.64
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$16.78
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$15.84
|
| Rate for Payer: Fidelis Essential Plan QHP |
$16.59
|
| Rate for Payer: Fidelis Medicare Advantage |
$18.64
|
| Rate for Payer: Fidelis Qualified Health Plan |
$16.59
|
| Rate for Payer: Group Health Inc Commercial |
$18.64
|
| Rate for Payer: Group Health Inc Medicare |
$18.64
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$18.64
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$18.64
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$18.64
|
| Rate for Payer: Healthfirst Medicare Advantage |
$18.64
|
| Rate for Payer: Healthfirst QHP |
$18.64
|
| Rate for Payer: Humana Medicare |
$19.01
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$18.64
|
| Rate for Payer: United Healthcare Commercial |
$17.34
|
| Rate for Payer: United Healthcare Medicare Advantage |
$18.64
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$18.64
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$17.71
|
| Rate for Payer: Wellcare Medicare |
$16.78
|
|
|
HC QUANTITATION DRUG NOT ELSEWHERE SPECIFIED - METHOTREXATE LEVEL
|
Facility
|
IP
|
$46.00
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
3018029903
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$23.00 |
| Max. Negotiated Rate |
$23.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$23.00
|
|
|
HC QUANTITATION DRUG NOT ELSEWHERE SPECIFIED - METHOTREXATE LEVEL
|
Facility
|
OP
|
$46.00
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
3018029903
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$13.05 |
| Max. Negotiated Rate |
$34.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$25.30
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$18.64
|
| Rate for Payer: Aetna Government |
$18.64
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$13.05
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$13.05
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$13.05
|
| Rate for Payer: Brighton Health Commercial |
$34.50
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$18.64
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$23.28
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$19.60
|
| Rate for Payer: Elderplan Medicare Advantage |
$18.64
|
| Rate for Payer: EmblemHealth Commercial |
$18.64
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$16.78
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$15.84
|
| Rate for Payer: Fidelis Essential Plan QHP |
$16.59
|
| Rate for Payer: Fidelis Medicare Advantage |
$18.64
|
| Rate for Payer: Fidelis Qualified Health Plan |
$16.59
|
| Rate for Payer: Group Health Inc Commercial |
$18.64
|
| Rate for Payer: Group Health Inc Medicare |
$18.64
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$18.64
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$18.64
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$18.64
|
| Rate for Payer: Healthfirst Medicare Advantage |
$18.64
|
| Rate for Payer: Healthfirst QHP |
$18.64
|
| Rate for Payer: Humana Medicare |
$19.01
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$18.64
|
| Rate for Payer: United Healthcare Commercial |
$17.34
|
| Rate for Payer: United Healthcare Medicare Advantage |
$18.64
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$18.64
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$17.71
|
| Rate for Payer: Wellcare Medicare |
$16.78
|
|
|
HC QUANTITATION DRUG NOT ELSEWHERE SPECIFIED - OXCARBAZEPINE METABOLITE
|
Facility
|
OP
|
$46.00
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
3018029904
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$13.05 |
| Max. Negotiated Rate |
$34.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$25.30
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$18.64
|
| Rate for Payer: Aetna Government |
$18.64
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$13.05
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$13.05
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$13.05
|
| Rate for Payer: Brighton Health Commercial |
$34.50
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$18.64
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$23.28
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$19.60
|
| Rate for Payer: Elderplan Medicare Advantage |
$18.64
|
| Rate for Payer: EmblemHealth Commercial |
$18.64
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$16.78
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$15.84
|
| Rate for Payer: Fidelis Essential Plan QHP |
$16.59
|
| Rate for Payer: Fidelis Medicare Advantage |
$18.64
|
| Rate for Payer: Fidelis Qualified Health Plan |
$16.59
|
| Rate for Payer: Group Health Inc Commercial |
$18.64
|
| Rate for Payer: Group Health Inc Medicare |
$18.64
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$18.64
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$18.64
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$18.64
|
| Rate for Payer: Healthfirst Medicare Advantage |
$18.64
|
| Rate for Payer: Healthfirst QHP |
$18.64
|
| Rate for Payer: Humana Medicare |
$19.01
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$18.64
|
| Rate for Payer: United Healthcare Commercial |
$17.34
|
| Rate for Payer: United Healthcare Medicare Advantage |
$18.64
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$18.64
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$17.71
|
| Rate for Payer: Wellcare Medicare |
$16.78
|
|
|
HC QUANTITATION DRUG NOT ELSEWHERE SPECIFIED - OXCARBAZEPINE METABOLITE
|
Facility
|
IP
|
$46.00
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
3018029904
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$23.00 |
| Max. Negotiated Rate |
$23.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$23.00
|
|
|
HC QUANTITATION DRUG NOT ELSEWHERE SPECIFIED - PROPRANOLOL LEVEL
|
Facility
|
OP
|
$46.00
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
3018029917
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$13.05 |
| Max. Negotiated Rate |
$34.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$25.30
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$18.64
|
| Rate for Payer: Aetna Government |
$18.64
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$13.05
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$13.05
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$13.05
|
| Rate for Payer: Brighton Health Commercial |
$34.50
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$18.64
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$23.28
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$19.60
|
| Rate for Payer: Elderplan Medicare Advantage |
$18.64
|
| Rate for Payer: EmblemHealth Commercial |
$18.64
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$16.78
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$15.84
|
| Rate for Payer: Fidelis Essential Plan QHP |
$16.59
|
| Rate for Payer: Fidelis Medicare Advantage |
$18.64
|
| Rate for Payer: Fidelis Qualified Health Plan |
$16.59
|
| Rate for Payer: Group Health Inc Commercial |
$18.64
|
| Rate for Payer: Group Health Inc Medicare |
$18.64
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$18.64
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$18.64
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$18.64
|
| Rate for Payer: Healthfirst Medicare Advantage |
$18.64
|
| Rate for Payer: Healthfirst QHP |
$18.64
|
| Rate for Payer: Humana Medicare |
$19.01
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$18.64
|
| Rate for Payer: United Healthcare Commercial |
$17.34
|
| Rate for Payer: United Healthcare Medicare Advantage |
$18.64
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$18.64
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$17.71
|
| Rate for Payer: Wellcare Medicare |
$16.78
|
|
|
HC QUANTITATION DRUG NOT ELSEWHERE SPECIFIED - PROPRANOLOL LEVEL
|
Facility
|
IP
|
$46.00
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
3018029917
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$23.00 |
| Max. Negotiated Rate |
$23.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$23.00
|
|
|
HC QUANTITATION DRUG NOT ELSEWHERE SPECIFIED - STREPTOMYCIN LEVEL
|
Facility
|
OP
|
$46.00
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
3018029902
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$13.05 |
| Max. Negotiated Rate |
$34.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$25.30
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$18.64
|
| Rate for Payer: Aetna Government |
$18.64
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$13.05
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$13.05
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$13.05
|
| Rate for Payer: Brighton Health Commercial |
$34.50
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$18.64
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$23.28
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$19.60
|
| Rate for Payer: Elderplan Medicare Advantage |
$18.64
|
| Rate for Payer: EmblemHealth Commercial |
$18.64
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$16.78
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$15.84
|
| Rate for Payer: Fidelis Essential Plan QHP |
$16.59
|
| Rate for Payer: Fidelis Medicare Advantage |
$18.64
|
| Rate for Payer: Fidelis Qualified Health Plan |
$16.59
|
| Rate for Payer: Group Health Inc Commercial |
$18.64
|
| Rate for Payer: Group Health Inc Medicare |
$18.64
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$18.64
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$18.64
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$18.64
|
| Rate for Payer: Healthfirst Medicare Advantage |
$18.64
|
| Rate for Payer: Healthfirst QHP |
$18.64
|
| Rate for Payer: Humana Medicare |
$19.01
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$18.64
|
| Rate for Payer: United Healthcare Commercial |
$17.34
|
| Rate for Payer: United Healthcare Medicare Advantage |
$18.64
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$18.64
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$17.71
|
| Rate for Payer: Wellcare Medicare |
$16.78
|
|
|
HC QUANTITATION DRUG NOT ELSEWHERE SPECIFIED - STREPTOMYCIN LEVEL
|
Facility
|
IP
|
$46.00
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
3018029902
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$23.00 |
| Max. Negotiated Rate |
$23.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$23.00
|
|
|
HC QUANTITATION DRUG NOT ELSEWHERE SPECIFIED - TIAGABINE (GABITRIL) LVL
|
Facility
|
IP
|
$46.00
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
3018029910
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$23.00 |
| Max. Negotiated Rate |
$23.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$23.00
|
|
|
HC QUANTITATION DRUG NOT ELSEWHERE SPECIFIED - TIAGABINE (GABITRIL) LVL
|
Facility
|
OP
|
$46.00
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
3018029910
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$13.05 |
| Max. Negotiated Rate |
$34.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$25.30
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$18.64
|
| Rate for Payer: Aetna Government |
$18.64
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$13.05
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$13.05
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$13.05
|
| Rate for Payer: Brighton Health Commercial |
$34.50
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$18.64
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$23.28
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$19.60
|
| Rate for Payer: Elderplan Medicare Advantage |
$18.64
|
| Rate for Payer: EmblemHealth Commercial |
$18.64
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$16.78
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$15.84
|
| Rate for Payer: Fidelis Essential Plan QHP |
$16.59
|
| Rate for Payer: Fidelis Medicare Advantage |
$18.64
|
| Rate for Payer: Fidelis Qualified Health Plan |
$16.59
|
| Rate for Payer: Group Health Inc Commercial |
$18.64
|
| Rate for Payer: Group Health Inc Medicare |
$18.64
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$18.64
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$18.64
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$18.64
|
| Rate for Payer: Healthfirst Medicare Advantage |
$18.64
|
| Rate for Payer: Healthfirst QHP |
$18.64
|
| Rate for Payer: Humana Medicare |
$19.01
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$18.64
|
| Rate for Payer: United Healthcare Commercial |
$17.34
|
| Rate for Payer: United Healthcare Medicare Advantage |
$18.64
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$18.64
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$17.71
|
| Rate for Payer: Wellcare Medicare |
$16.78
|
|
|
HC QUANTITATION DRUG NOT ELSEWHERE SPECIFIED - ZONISAMIDE LEVEL
|
Facility
|
IP
|
$46.00
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
3018029911
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$23.00 |
| Max. Negotiated Rate |
$23.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$23.00
|
|
|
HC QUANTITATION DRUG NOT ELSEWHERE SPECIFIED - ZONISAMIDE LEVEL
|
Facility
|
OP
|
$46.00
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
3018029911
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$13.05 |
| Max. Negotiated Rate |
$34.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$25.30
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$18.64
|
| Rate for Payer: Aetna Government |
$18.64
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$13.05
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$13.05
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$13.05
|
| Rate for Payer: Brighton Health Commercial |
$34.50
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$18.64
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$23.28
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$19.60
|
| Rate for Payer: Elderplan Medicare Advantage |
$18.64
|
| Rate for Payer: EmblemHealth Commercial |
$18.64
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$16.78
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$15.84
|
| Rate for Payer: Fidelis Essential Plan QHP |
$16.59
|
| Rate for Payer: Fidelis Medicare Advantage |
$18.64
|
| Rate for Payer: Fidelis Qualified Health Plan |
$16.59
|
| Rate for Payer: Group Health Inc Commercial |
$18.64
|
| Rate for Payer: Group Health Inc Medicare |
$18.64
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$18.64
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$18.64
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$18.64
|
| Rate for Payer: Healthfirst Medicare Advantage |
$18.64
|
| Rate for Payer: Healthfirst QHP |
$18.64
|
| Rate for Payer: Humana Medicare |
$19.01
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$18.64
|
| Rate for Payer: United Healthcare Commercial |
$17.34
|
| Rate for Payer: United Healthcare Medicare Advantage |
$18.64
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$18.64
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$17.71
|
| Rate for Payer: Wellcare Medicare |
$16.78
|
|
|
HC QUANTITATIVE SCREEN, METALS - COBALT
|
Facility
|
IP
|
$54.00
|
|
|
Service Code
|
CPT 83018
|
| Hospital Charge Code |
3018301801
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$27.00 |
| Max. Negotiated Rate |
$27.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$27.00
|
|
|
HC QUANTITATIVE SCREEN, METALS - COBALT
|
Facility
|
OP
|
$54.00
|
|
|
Service Code
|
CPT 83018
|
| Hospital Charge Code |
3018301801
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$15.37 |
| Max. Negotiated Rate |
$40.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$29.70
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$21.96
|
| Rate for Payer: Aetna Government |
$21.96
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$15.37
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$15.37
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$15.37
|
| Rate for Payer: Brighton Health Commercial |
$40.50
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$21.96
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$37.34
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$31.43
|
| Rate for Payer: Elderplan Medicare Advantage |
$21.96
|
| Rate for Payer: EmblemHealth Commercial |
$21.96
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$19.76
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$18.67
|
| Rate for Payer: Fidelis Essential Plan QHP |
$19.54
|
| Rate for Payer: Fidelis Medicare Advantage |
$21.96
|
| Rate for Payer: Fidelis Qualified Health Plan |
$19.54
|
| Rate for Payer: Group Health Inc Commercial |
$21.96
|
| Rate for Payer: Group Health Inc Medicare |
$21.96
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$21.96
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$21.96
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$21.96
|
| Rate for Payer: Healthfirst Medicare Advantage |
$21.96
|
| Rate for Payer: Healthfirst QHP |
$21.96
|
| Rate for Payer: Humana Medicare |
$22.40
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$21.96
|
| Rate for Payer: United Healthcare Commercial |
$27.82
|
| Rate for Payer: United Healthcare Medicare Advantage |
$21.96
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$21.96
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$20.86
|
| Rate for Payer: Wellcare Medicare |
$19.76
|
|
|
HC RABIES IG,IM/SC
|
Facility
|
OP
|
$864.00
|
|
|
Service Code
|
CPT 90375
|
| Hospital Charge Code |
6369037501
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$195.90 |
| Max. Negotiated Rate |
$561.60 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$475.20
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$279.85
|
| Rate for Payer: Aetna Government |
$279.85
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$195.90
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$195.90
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$195.90
|
| Rate for Payer: Brighton Health Commercial |
$518.40
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$279.85
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$432.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$496.80
|
| Rate for Payer: Elderplan Medicare Advantage |
$279.85
|
| Rate for Payer: EmblemHealth Commercial |
$279.85
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$279.85
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$279.85
|
| Rate for Payer: Fidelis Essential Plan QHP |
$293.84
|
| Rate for Payer: Fidelis Medicare Advantage |
$279.85
|
| Rate for Payer: Fidelis Qualified Health Plan |
$293.84
|
| Rate for Payer: Group Health Inc Commercial |
$279.85
|
| Rate for Payer: Group Health Inc Medicare |
$279.85
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$432.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$432.00
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$279.85
|
| Rate for Payer: Healthfirst Commercial |
$456.16
|
| Rate for Payer: Healthfirst Essential Plan |
$279.85
|
| Rate for Payer: Healthfirst Medicare Advantage |
$237.87
|
| Rate for Payer: Healthfirst QHP |
$279.85
|
| Rate for Payer: Humana Medicare |
$285.45
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$279.85
|
| Rate for Payer: United Healthcare Commercial |
$278.24
|
| Rate for Payer: United Healthcare Medicare Advantage |
$279.85
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$561.60
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$265.86
|
| Rate for Payer: Wellcare Medicare |
$265.86
|
|
|
HC RABIES IG,IM/SC
|
Facility
|
IP
|
$864.00
|
|
|
Service Code
|
CPT 90375
|
| Hospital Charge Code |
6369037501
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$432.00 |
| Max. Negotiated Rate |
$432.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$432.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$432.00
|
|
|
HC RABIES IG MINIDOES IM
|
Facility
|
OP
|
$864.00
|
|
|
Service Code
|
CPT 90385
|
| Hospital Charge Code |
6369038501
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$29.53 |
| Max. Negotiated Rate |
$561.60 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$475.20
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$29.53
|
| Rate for Payer: Aetna Government |
$29.53
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$193.66
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$193.66
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$86.07
|
| Rate for Payer: Amida Care Medicaid |
$86.07
|
| Rate for Payer: Brighton Health Commercial |
$518.40
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$432.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$496.80
|
| Rate for Payer: EmblemHealth Commercial |
$432.00
|
| Rate for Payer: EmblemHealth Essential Plan 1&2 |
$193.66
|
| Rate for Payer: EmblemHealth Essential Plan 3&4 |
$86.07
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$86.07
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$193.66
|
| Rate for Payer: Fidelis Essential Plan QHP |
$193.66
|
| Rate for Payer: Fidelis Qualified Health Plan |
$90.37
|
| Rate for Payer: Group Health Inc Commercial |
$432.00
|
| Rate for Payer: Group Health Inc Medicare |
$302.40
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$86.07
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$432.00
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$86.07
|
| Rate for Payer: Healthfirst Essential Plan |
$193.66
|
| Rate for Payer: Healthfirst QHP |
$140.29
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$86.07
|
| Rate for Payer: SOMOS Essential |
$193.66
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$193.66
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$94.67
|
| Rate for Payer: United Healthcare Medicaid |
$86.07
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$561.60
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$86.07
|
|
|
HC RABIES IG MINIDOES IM
|
Facility
|
IP
|
$864.00
|
|
|
Service Code
|
CPT 90385
|
| Hospital Charge Code |
6369038501
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$432.00 |
| Max. Negotiated Rate |
$432.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$432.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$432.00
|
|
|
HC RABIES VACCINE, IM
|
Facility
|
OP
|
$855.00
|
|
|
Service Code
|
CPT 90675
|
| Hospital Charge Code |
6369067501
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$219.58 |
| Max. Negotiated Rate |
$555.75 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$470.25
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$313.68
|
| Rate for Payer: Aetna Government |
$313.68
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$219.58
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$219.58
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$219.58
|
| Rate for Payer: Brighton Health Commercial |
$513.00
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$313.68
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$427.50
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$491.62
|
| Rate for Payer: Elderplan Medicare Advantage |
$313.68
|
| Rate for Payer: EmblemHealth Commercial |
$313.68
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$313.68
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$313.68
|
| Rate for Payer: Fidelis Essential Plan QHP |
$329.36
|
| Rate for Payer: Fidelis Medicare Advantage |
$313.68
|
| Rate for Payer: Fidelis Qualified Health Plan |
$329.36
|
| Rate for Payer: Group Health Inc Commercial |
$313.68
|
| Rate for Payer: Group Health Inc Medicare |
$313.68
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$427.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$427.50
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$313.68
|
| Rate for Payer: Healthfirst Commercial |
$511.30
|
| Rate for Payer: Healthfirst Essential Plan |
$313.68
|
| Rate for Payer: Healthfirst Medicare Advantage |
$266.63
|
| Rate for Payer: Healthfirst QHP |
$313.68
|
| Rate for Payer: Humana Medicare |
$319.95
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$313.68
|
| Rate for Payer: United Healthcare Commercial |
$355.22
|
| Rate for Payer: United Healthcare Medicare Advantage |
$313.68
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$555.75
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$298.00
|
| Rate for Payer: Wellcare Medicare |
$298.00
|
|
|
HC RABIES VACCINE, IM
|
Facility
|
IP
|
$855.00
|
|
|
Service Code
|
CPT 90675
|
| Hospital Charge Code |
6369067501
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$427.50 |
| Max. Negotiated Rate |
$427.50 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$427.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$427.50
|
|
