|
FACTOR VIII/1 - CHARGE ONLY
|
Facility
OP
|
$44.75
|
|
|
Service Code
|
HCPCS 85240
|
| Hospital Charge Code |
40701076
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$14.32 |
| Max. Negotiated Rate |
$28.47 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$24.61
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$17.90
|
| Rate for Payer: Aetna Government |
$17.90
|
| Rate for Payer: Cash Price |
$17.90
|
| Rate for Payer: Cash Price |
$17.90
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$17.90
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$28.47
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$24.09
|
| Rate for Payer: Elderplan Medicare Advantage |
$17.90
|
| Rate for Payer: EmblemHealth Commercial |
$17.90
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$16.11
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$15.22
|
| Rate for Payer: Fidelis Essential Plan QHP |
$15.93
|
| Rate for Payer: Fidelis Medicare Advantage |
$17.90
|
| Rate for Payer: Fidelis Qualified Health Plan |
$15.93
|
| Rate for Payer: Group Health Inc Commercial |
$17.90
|
| Rate for Payer: Group Health Inc Medicare |
$17.90
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$22.38
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$17.90
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$17.90
|
| Rate for Payer: Healthfirst Medicare Advantage |
$17.90
|
| Rate for Payer: Healthfirst QHP |
$17.90
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$17.90
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$17.90
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$14.32
|
| Rate for Payer: Wellcare Medicare |
$16.11
|
|
|
FACTOR_VIII_ACTIVITY
|
Facility
OP
|
$44.75
|
|
|
Service Code
|
HCPCS 85240
|
| Hospital Charge Code |
40629210
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$14.32 |
| Max. Negotiated Rate |
$28.47 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$24.61
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$17.90
|
| Rate for Payer: Aetna Government |
$17.90
|
| Rate for Payer: Cash Price |
$17.90
|
| Rate for Payer: Cash Price |
$17.90
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$17.90
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$28.47
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$24.09
|
| Rate for Payer: Elderplan Medicare Advantage |
$17.90
|
| Rate for Payer: EmblemHealth Commercial |
$17.90
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$16.11
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$15.22
|
| Rate for Payer: Fidelis Essential Plan QHP |
$15.93
|
| Rate for Payer: Fidelis Medicare Advantage |
$17.90
|
| Rate for Payer: Fidelis Qualified Health Plan |
$15.93
|
| Rate for Payer: Group Health Inc Commercial |
$17.90
|
| Rate for Payer: Group Health Inc Medicare |
$17.90
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$22.38
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$17.90
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$17.90
|
| Rate for Payer: Healthfirst Medicare Advantage |
$17.90
|
| Rate for Payer: Healthfirst QHP |
$17.90
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$17.90
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$17.90
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$14.32
|
| Rate for Payer: Wellcare Medicare |
$16.11
|
|
|
FACTOR V (LEIDEN) MUTATI
|
Facility
OP
|
$183.43
|
|
|
Service Code
|
HCPCS 81241
|
| Hospital Charge Code |
30305800
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$58.70 |
| Max. Negotiated Rate |
$146.74 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$100.89
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$73.37
|
| Rate for Payer: Aetna Government |
$73.37
|
| Rate for Payer: Brighton Health Commercial |
$73.37
|
| Rate for Payer: Cash Price |
$73.37
|
| Rate for Payer: Cash Price |
$73.37
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$73.37
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$146.74
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$124.73
|
| Rate for Payer: Elderplan Medicare Advantage |
$73.37
|
| Rate for Payer: EmblemHealth Commercial |
$73.37
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$66.03
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$62.36
|
| Rate for Payer: Fidelis Essential Plan QHP |
$65.30
|
| Rate for Payer: Fidelis Medicare Advantage |
$73.37
|
| Rate for Payer: Fidelis Qualified Health Plan |
$65.30
|
| Rate for Payer: Group Health Inc Commercial |
$73.37
|
| Rate for Payer: Group Health Inc Medicare |
$73.37
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$91.72
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$73.37
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$73.37
|
| Rate for Payer: Healthfirst Medicare Advantage |
$73.37
|
| Rate for Payer: Healthfirst QHP |
$73.37
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$73.37
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$73.37
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$58.70
|
| Rate for Payer: Wellcare Medicare |
$66.03
|
|
|
FACTOR V LEIDEN MUTATION
|
Facility
OP
|
$183.43
|
|
|
Service Code
|
HCPCS 81241
|
| Hospital Charge Code |
40629204
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$58.70 |
| Max. Negotiated Rate |
$146.74 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$100.89
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$73.37
|
| Rate for Payer: Aetna Government |
$73.37
|
| Rate for Payer: Brighton Health Commercial |
$73.37
|
| Rate for Payer: Cash Price |
$73.37
|
| Rate for Payer: Cash Price |
$73.37
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$73.37
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$146.74
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$124.73
|
| Rate for Payer: Elderplan Medicare Advantage |
$73.37
|
| Rate for Payer: EmblemHealth Commercial |
$73.37
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$66.03
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$62.36
|
| Rate for Payer: Fidelis Essential Plan QHP |
$65.30
|
| Rate for Payer: Fidelis Medicare Advantage |
$73.37
|
| Rate for Payer: Fidelis Qualified Health Plan |
$65.30
|
| Rate for Payer: Group Health Inc Commercial |
$73.37
|
| Rate for Payer: Group Health Inc Medicare |
$73.37
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$91.72
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$73.37
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$73.37
|
| Rate for Payer: Healthfirst Medicare Advantage |
$73.37
|
| Rate for Payer: Healthfirst QHP |
$73.37
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$73.37
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$73.37
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$58.70
|
| Rate for Payer: Wellcare Medicare |
$66.03
|
|
|
FACTOR X ACTIVITY
|
Facility
OP
|
$44.75
|
|
|
Service Code
|
HCPCS 85260
|
| Hospital Charge Code |
40629213
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$14.32 |
| Max. Negotiated Rate |
$28.47 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$24.61
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$17.90
|
| Rate for Payer: Aetna Government |
$17.90
|
| Rate for Payer: Cash Price |
$17.90
|
| Rate for Payer: Cash Price |
$17.90
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$17.90
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$28.47
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$24.09
|
| Rate for Payer: Elderplan Medicare Advantage |
$17.90
|
| Rate for Payer: EmblemHealth Commercial |
$17.90
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$16.11
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$15.22
|
| Rate for Payer: Fidelis Essential Plan QHP |
$15.93
|
| Rate for Payer: Fidelis Medicare Advantage |
$17.90
|
| Rate for Payer: Fidelis Qualified Health Plan |
$15.93
|
| Rate for Payer: Group Health Inc Commercial |
$17.90
|
| Rate for Payer: Group Health Inc Medicare |
$17.90
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$22.38
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$17.90
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$17.90
|
| Rate for Payer: Healthfirst Medicare Advantage |
$17.90
|
| Rate for Payer: Healthfirst QHP |
$17.90
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$17.90
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$17.90
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$14.32
|
| Rate for Payer: Wellcare Medicare |
$16.11
|
|
|
FACTOR X CHROMOGENIC
|
Facility
OP
|
$44.75
|
|
|
Service Code
|
HCPCS 85260
|
| Hospital Charge Code |
40629739
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$14.32 |
| Max. Negotiated Rate |
$28.47 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$24.61
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$17.90
|
| Rate for Payer: Aetna Government |
$17.90
|
| Rate for Payer: Cash Price |
$17.90
|
| Rate for Payer: Cash Price |
$17.90
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$17.90
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$28.47
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$24.09
|
| Rate for Payer: Elderplan Medicare Advantage |
$17.90
|
| Rate for Payer: EmblemHealth Commercial |
$17.90
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$16.11
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$15.22
|
| Rate for Payer: Fidelis Essential Plan QHP |
$15.93
|
| Rate for Payer: Fidelis Medicare Advantage |
$17.90
|
| Rate for Payer: Fidelis Qualified Health Plan |
$15.93
|
| Rate for Payer: Group Health Inc Commercial |
$17.90
|
| Rate for Payer: Group Health Inc Medicare |
$17.90
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$22.38
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$17.90
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$17.90
|
| Rate for Payer: Healthfirst Medicare Advantage |
$17.90
|
| Rate for Payer: Healthfirst QHP |
$17.90
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$17.90
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$17.90
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$14.32
|
| Rate for Payer: Wellcare Medicare |
$16.11
|
|
|
FACTOR_XI_ACTIVITY
|
Facility
OP
|
$44.75
|
|
|
Service Code
|
HCPCS 85270
|
| Hospital Charge Code |
40629734
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$14.32 |
| Max. Negotiated Rate |
$28.47 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$24.61
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$17.90
|
| Rate for Payer: Aetna Government |
$17.90
|
| Rate for Payer: Cash Price |
$17.90
|
| Rate for Payer: Cash Price |
$17.90
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$17.90
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$28.47
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$24.09
|
| Rate for Payer: Elderplan Medicare Advantage |
$17.90
|
| Rate for Payer: EmblemHealth Commercial |
$17.90
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$16.11
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$15.22
|
| Rate for Payer: Fidelis Essential Plan QHP |
$15.93
|
| Rate for Payer: Fidelis Medicare Advantage |
$17.90
|
| Rate for Payer: Fidelis Qualified Health Plan |
$15.93
|
| Rate for Payer: Group Health Inc Commercial |
$17.90
|
| Rate for Payer: Group Health Inc Medicare |
$17.90
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$22.38
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$17.90
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$17.90
|
| Rate for Payer: Healthfirst Medicare Advantage |
$17.90
|
| Rate for Payer: Healthfirst QHP |
$17.90
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$17.90
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$17.90
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$14.32
|
| Rate for Payer: Wellcare Medicare |
$16.11
|
|
|
FACTOR_XII_ACTIVITY
|
Facility
OP
|
$48.38
|
|
|
Service Code
|
HCPCS 85280
|
| Hospital Charge Code |
40629735
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$15.48 |
| Max. Negotiated Rate |
$30.74 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$26.61
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$19.35
|
| Rate for Payer: Aetna Government |
$19.35
|
| Rate for Payer: Cash Price |
$19.35
|
| Rate for Payer: Cash Price |
$19.35
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$19.35
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$30.74
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$26.02
|
| Rate for Payer: Elderplan Medicare Advantage |
$19.35
|
| Rate for Payer: EmblemHealth Commercial |
$19.35
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$17.42
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$16.45
|
| Rate for Payer: Fidelis Essential Plan QHP |
$17.22
|
| Rate for Payer: Fidelis Medicare Advantage |
$19.35
|
| Rate for Payer: Fidelis Qualified Health Plan |
$17.22
|
| Rate for Payer: Group Health Inc Commercial |
$19.35
|
| Rate for Payer: Group Health Inc Medicare |
$19.35
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$24.19
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$19.35
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$19.35
|
| Rate for Payer: Healthfirst Medicare Advantage |
$19.35
|
| Rate for Payer: Healthfirst QHP |
$19.35
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$19.35
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$19.35
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$15.48
|
| Rate for Payer: Wellcare Medicare |
$17.42
|
|
|
FACTOR_XIII_ACTIVITY
|
Facility
OP
|
$40.85
|
|
|
Service Code
|
HCPCS 85290
|
| Hospital Charge Code |
40629861
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$13.07 |
| Max. Negotiated Rate |
$25.97 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$22.47
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$16.34
|
| Rate for Payer: Aetna Government |
$16.34
|
| Rate for Payer: Cash Price |
$16.34
|
| Rate for Payer: Cash Price |
$16.34
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$16.34
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$25.97
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$21.98
|
| Rate for Payer: Elderplan Medicare Advantage |
$16.34
|
| Rate for Payer: EmblemHealth Commercial |
$16.34
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$14.71
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$13.89
|
| Rate for Payer: Fidelis Essential Plan QHP |
$14.54
|
| Rate for Payer: Fidelis Medicare Advantage |
$16.34
|
| Rate for Payer: Fidelis Qualified Health Plan |
$14.54
|
| Rate for Payer: Group Health Inc Commercial |
$16.34
|
| Rate for Payer: Group Health Inc Medicare |
$16.34
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$20.42
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$16.34
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$16.34
|
| Rate for Payer: Healthfirst Medicare Advantage |
$16.34
|
| Rate for Payer: Healthfirst QHP |
$16.34
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$16.34
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$16.34
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$13.07
|
| Rate for Payer: Wellcare Medicare |
$14.71
|
|
|
FALLIUM GA-67
|
Facility
OP
|
$17.95
|
|
|
Service Code
|
HCPCS A9556
|
| Hospital Charge Code |
41646584
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$6.28 |
| Max. Negotiated Rate |
$99.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$9.87
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$99.50
|
| Rate for Payer: Aetna Government |
$99.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$14.36
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$12.21
|
| Rate for Payer: Group Health Inc Commercial |
$8.98
|
| Rate for Payer: Group Health Inc Medicare |
$6.28
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$8.98
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$8.98
|
|
|
FALL RISK ASSESSMENT DOCD
|
Facility
OP
|
$0.01
|
|
|
Service Code
|
HCPCS 3288F
|
| Hospital Charge Code |
30307898
|
|
Hospital Revenue Code
|
969
|
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.01
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.01
|
| Rate for Payer: Aetna Government |
$0.01
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2,915.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,477.75
|
| Rate for Payer: Group Health Inc Commercial |
$0.01
|
| Rate for Payer: Group Health Inc Medicare |
$0.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.01
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.01
|
|
|
FAMCICLOVIR 500MG CAP
|
Facility
OP
|
$8.00
|
|
| Hospital Charge Code |
41647275
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.80 |
| Max. Negotiated Rate |
$6.40 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$4.40
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$4.00
|
| Rate for Payer: Aetna Government |
$4.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$6.40
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$5.44
|
| Rate for Payer: Group Health Inc Commercial |
$4.00
|
| Rate for Payer: Group Health Inc Medicare |
$2.80
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$5.20
|
|
|
FAMCICLOVIR 500MG CAP
|
Facility
OP
|
$8.00
|
|
| Hospital Charge Code |
41657275
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.80 |
| Max. Negotiated Rate |
$6.40 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$4.40
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$4.00
|
| Rate for Payer: Aetna Government |
$4.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$6.40
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$5.44
|
| Rate for Payer: Group Health Inc Commercial |
$4.00
|
| Rate for Payer: Group Health Inc Medicare |
$2.80
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$5.20
|
|
|
FAMILIAL DYSAUTONOMIA, DNA
|
Facility
OP
|
$98.28
|
|
|
Service Code
|
HCPCS 81260
|
| Hospital Charge Code |
40603051
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$31.45 |
| Max. Negotiated Rate |
$78.62 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$54.05
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$39.31
|
| Rate for Payer: Aetna Government |
$39.31
|
| Rate for Payer: Cash Price |
$39.31
|
| Rate for Payer: Cash Price |
$39.31
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$39.31
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$78.62
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$66.83
|
| Rate for Payer: Elderplan Medicare Advantage |
$39.31
|
| Rate for Payer: EmblemHealth Commercial |
$39.31
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$35.38
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$33.41
|
| Rate for Payer: Fidelis Essential Plan QHP |
$34.99
|
| Rate for Payer: Fidelis Medicare Advantage |
$39.31
|
| Rate for Payer: Fidelis Qualified Health Plan |
$34.99
|
| Rate for Payer: Group Health Inc Commercial |
$39.31
|
| Rate for Payer: Group Health Inc Medicare |
$39.31
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$49.14
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$39.31
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$39.31
|
| Rate for Payer: Healthfirst Medicare Advantage |
$39.31
|
| Rate for Payer: Healthfirst QHP |
$39.31
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$39.31
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$39.31
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$31.45
|
| Rate for Payer: Wellcare Medicare |
$35.38
|
|
|
FAMILY THERAPY W/O PATIENT
|
Facility
OP
|
$397.85
|
|
|
Service Code
|
HCPCS 90846
|
| Hospital Charge Code |
30400083
|
|
Hospital Revenue Code
|
905
|
| Min. Negotiated Rate |
$94.79 |
| Max. Negotiated Rate |
$318.28 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$218.82
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$184.38
|
| Rate for Payer: Aetna Government |
$184.38
|
| Rate for Payer: Carelon Behavioral Health Medicare Advantage |
$184.38
|
| Rate for Payer: Cash Price |
$184.38
|
| Rate for Payer: Cash Price |
$184.38
|
| Rate for Payer: Cash Price |
$184.38
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$184.38
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$318.28
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$270.54
|
| Rate for Payer: Elderplan Medicare Advantage |
$184.38
|
| Rate for Payer: EmblemHealth Commercial |
$184.38
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$94.79
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$156.72
|
| Rate for Payer: Fidelis Essential Plan QHP |
$164.10
|
| Rate for Payer: Fidelis Medicare Advantage |
$184.38
|
| Rate for Payer: Fidelis Qualified Health Plan |
$164.10
|
| Rate for Payer: Group Health Inc Commercial |
$184.38
|
| Rate for Payer: Group Health Inc Medicare |
$184.38
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$198.92
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$184.38
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$105.32
|
| Rate for Payer: Healthfirst Medicare Advantage |
$156.72
|
| Rate for Payer: Healthfirst QHP |
$184.38
|
| Rate for Payer: Optum Commercial/Medicare |
$143.00
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$184.38
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$184.38
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$147.50
|
| Rate for Payer: Wellcare Medicare |
$175.16
|
|
|
FAMILY THERAPY W/PATIENT
|
Facility
OP
|
$397.85
|
|
|
Service Code
|
HCPCS 90847
|
| Hospital Charge Code |
30400084
|
|
Hospital Revenue Code
|
905
|
| Min. Negotiated Rate |
$143.00 |
| Max. Negotiated Rate |
$26,116.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$218.82
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$184.38
|
| Rate for Payer: Aetna Government |
$184.38
|
| Rate for Payer: Amida Care Medicaid |
$261.16
|
| Rate for Payer: Carelon Behavioral Health HARP/QHP |
$263.54
|
| Rate for Payer: Carelon Behavioral Health Medicare Advantage |
$184.38
|
| Rate for Payer: Cash Price |
$184.38
|
| Rate for Payer: Cash Price |
$184.38
|
| Rate for Payer: Cash Price |
$184.38
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$184.38
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$318.28
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$270.54
|
| Rate for Payer: Elderplan Medicare Advantage |
$184.38
|
| Rate for Payer: EmblemHealth Commercial |
$184.38
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$26,116.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$261.16
|
| Rate for Payer: Fidelis Essential Plan QHP |
$261.16
|
| Rate for Payer: Fidelis Medicare Advantage |
$184.38
|
| Rate for Payer: Fidelis Qualified Health Plan |
$274.22
|
| Rate for Payer: Group Health Inc Commercial |
$184.38
|
| Rate for Payer: Group Health Inc Medicare |
$184.38
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$261.16
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$184.38
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$261.16
|
| Rate for Payer: Healthfirst Essential Plan |
$587.61
|
| Rate for Payer: Healthfirst Medicare Advantage |
$156.72
|
| Rate for Payer: Healthfirst QHP |
$261.16
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$263.54
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$592.96
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$592.96
|
| Rate for Payer: Optum Commercial/Medicare |
$143.00
|
| Rate for Payer: Optum Medicaid |
$263.54
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$184.38
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$261.16
|
| Rate for Payer: SOMOS Essential |
$587.61
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$184.38
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$147.50
|
| Rate for Payer: Wellcare Medicare |
$175.16
|
|
|
FAMOTIDINE 10MG ML PED SYRINGE
|
Facility
OP
|
$1.03
|
|
| Hospital Charge Code |
41648052
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$0.82 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.57
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.52
|
| Rate for Payer: Aetna Government |
$0.52
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.82
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.70
|
| Rate for Payer: Group Health Inc Commercial |
$0.52
|
| Rate for Payer: Group Health Inc Medicare |
$0.36
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.52
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.52
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.67
|
|
|
FAMOTIDINE 10MG ML PED SYRINGE
|
Facility
OP
|
$1.03
|
|
| Hospital Charge Code |
41658052
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$0.82 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.57
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.52
|
| Rate for Payer: Aetna Government |
$0.52
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.82
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.70
|
| Rate for Payer: Group Health Inc Commercial |
$0.52
|
| Rate for Payer: Group Health Inc Medicare |
$0.36
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.52
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.52
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.67
|
|
|
FAMOTIDINE 10MG TAB
|
Facility
OP
|
$0.11
|
|
| Hospital Charge Code |
41648051
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.06
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.06
|
| Rate for Payer: Aetna Government |
$0.06
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.09
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.07
|
| Rate for Payer: Group Health Inc Commercial |
$0.06
|
| Rate for Payer: Group Health Inc Medicare |
$0.04
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.06
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.06
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.07
|
|
|
FAMOTIDINE 10MG TAB
|
Facility
OP
|
$0.11
|
|
| Hospital Charge Code |
41658051
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.06
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.06
|
| Rate for Payer: Aetna Government |
$0.06
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.09
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.07
|
| Rate for Payer: Group Health Inc Commercial |
$0.06
|
| Rate for Payer: Group Health Inc Medicare |
$0.04
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.06
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.06
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.07
|
|
|
FAMOTIDINE 20MG/50ML PRMX IVPB
|
Facility
OP
|
$6.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
41646075
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.10 |
| Max. Negotiated Rate |
$3.90 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$3.30
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3.00
|
| Rate for Payer: Aetna Government |
$3.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$3.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$3.45
|
| Rate for Payer: Group Health Inc Commercial |
$3.00
|
| Rate for Payer: Group Health Inc Medicare |
$2.10
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$3.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$3.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3.90
|
|
|
FAMOTIDINE 20MG/50ML PRMX IVPB
|
Facility
IP
|
$6.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
41646075
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.00 |
| Max. Negotiated Rate |
$3.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$3.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$3.00
|
|
|
FAMOTIDINE 20MG/50ML PRMX IVPB
|
Facility
OP
|
$6.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
41656075
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.10 |
| Max. Negotiated Rate |
$3.90 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$3.30
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3.00
|
| Rate for Payer: Aetna Government |
$3.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$3.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$3.45
|
| Rate for Payer: Group Health Inc Commercial |
$3.00
|
| Rate for Payer: Group Health Inc Medicare |
$2.10
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$3.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$3.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3.90
|
|
|
FAMOTIDINE 20MG/50ML PRMX IVPB
|
Facility
IP
|
$6.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
41656075
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.00 |
| Max. Negotiated Rate |
$3.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$3.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$3.00
|
|
|
FAMOTIDINE 20MG TAB
|
Facility
IP
|
$1.00
|
|
|
Service Code
|
HCPCS S0028
|
| Hospital Charge Code |
41658033
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$0.50 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.50
|
|
