|
ALPRAZOLAM 0.25 MG TAB
|
Facility
OP
|
$1.00
|
|
| Hospital Charge Code |
41640899
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$0.80 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.55
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.50
|
| Rate for Payer: Aetna Government |
$0.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.80
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.68
|
| Rate for Payer: Group Health Inc Commercial |
$0.50
|
| Rate for Payer: Group Health Inc Medicare |
$0.35
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.65
|
|
|
ALPRAZOLAM 0.5 MG TAB
|
Facility
OP
|
$0.10
|
|
| Hospital Charge Code |
41654039
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.06
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.05
|
| Rate for Payer: Aetna Government |
$0.05
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.08
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.07
|
| Rate for Payer: Group Health Inc Commercial |
$0.05
|
| Rate for Payer: Group Health Inc Medicare |
$0.04
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.05
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.05
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.07
|
|
|
ALPRAZOLAM 0.5 MG TAB
|
Facility
OP
|
$0.10
|
|
| Hospital Charge Code |
41644039
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.06
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.05
|
| Rate for Payer: Aetna Government |
$0.05
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.08
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.07
|
| Rate for Payer: Group Health Inc Commercial |
$0.05
|
| Rate for Payer: Group Health Inc Medicare |
$0.04
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.05
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.05
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.07
|
|
|
ALPROSTADIL 0.5 MG/ML INJ NEONATAL
|
Facility
IP
|
$0.15
|
|
|
Service Code
|
HCPCS J0270
|
| Hospital Charge Code |
41651436
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.08
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.08
|
|
|
ALPROSTADIL 0.5 MG/ML INJ NEONATAL
|
Facility
OP
|
$0.15
|
|
|
Service Code
|
HCPCS J0270
|
| Hospital Charge Code |
41651436
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$7.41 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.08
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$7.41
|
| Rate for Payer: Aetna Government |
$7.41
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.08
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.09
|
| Rate for Payer: Group Health Inc Commercial |
$0.08
|
| Rate for Payer: Group Health Inc Medicare |
$0.05
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.08
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.08
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.10
|
|
|
ALPROSTADIL 0.5 MG/ML INJ NEONATAL
|
Facility
OP
|
$0.15
|
|
|
Service Code
|
HCPCS J0270
|
| Hospital Charge Code |
41641436
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$7.41 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.08
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$7.41
|
| Rate for Payer: Aetna Government |
$7.41
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.08
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.09
|
| Rate for Payer: Group Health Inc Commercial |
$0.08
|
| Rate for Payer: Group Health Inc Medicare |
$0.05
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.08
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.08
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.10
|
|
|
ALPROSTADIL 0.5 MG/ML INJ NEONATAL
|
Facility
IP
|
$0.15
|
|
|
Service Code
|
HCPCS J0270
|
| Hospital Charge Code |
41641436
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.08
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.08
|
|
|
ALTEPLASE 100 MG INJ
|
Facility
OP
|
$82.95
|
|
|
Service Code
|
HCPCS J2997
|
| Hospital Charge Code |
41650944
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$41.48 |
| Max. Negotiated Rate |
$7,378.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$45.62
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$88.97
|
| Rate for Payer: Aetna Government |
$88.97
|
| Rate for Payer: Amida Care Medicaid |
$73.78
|
| Rate for Payer: Cash Price |
$88.97
|
| Rate for Payer: Cash Price |
$88.97
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$88.97
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$41.48
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$47.70
|
| Rate for Payer: Elderplan Medicare Advantage |
$88.97
|
| Rate for Payer: EmblemHealth Commercial |
$88.97
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$7,378.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$73.78
|
| Rate for Payer: Fidelis Essential Plan QHP |
$73.78
|
| Rate for Payer: Fidelis Medicare Advantage |
$88.97
|
| Rate for Payer: Fidelis Qualified Health Plan |
$77.47
|
| Rate for Payer: Group Health Inc Commercial |
$88.97
|
| Rate for Payer: Group Health Inc Medicare |
$88.97
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$73.78
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$41.48
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$73.78
|
| Rate for Payer: Healthfirst Essential Plan |
$73.78
|
| Rate for Payer: Healthfirst Medicare Advantage |
$75.63
|
| Rate for Payer: Healthfirst QHP |
$73.78
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$88.97
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$73.78
|
| Rate for Payer: SOMOS Essential |
$73.78
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$53.92
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$71.18
|
| Rate for Payer: Wellcare Medicare |
$84.53
|
|
|
ALTEPLASE 100 MG INJ
|
Facility
IP
|
$82.95
|
|
|
Service Code
|
HCPCS J2997
|
| Hospital Charge Code |
41650944
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$41.48 |
| Max. Negotiated Rate |
$41.48 |
| Rate for Payer: Cash Price |
$88.97
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$41.48
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$41.48
|
|
|
ALTEPLASE 100 MG INJ
|
Facility
IP
|
$82.95
|
|
|
Service Code
|
HCPCS J2997
|
| Hospital Charge Code |
41640944
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$41.48 |
| Max. Negotiated Rate |
$41.48 |
| Rate for Payer: Cash Price |
$88.97
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$41.48
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$41.48
|
|
|
ALTEPLASE 100 MG INJ
|
Facility
OP
|
$82.95
|
|
|
Service Code
|
HCPCS J2997
|
| Hospital Charge Code |
41640944
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$41.48 |
| Max. Negotiated Rate |
$7,378.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$45.62
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$88.97
|
| Rate for Payer: Aetna Government |
$88.97
|
| Rate for Payer: Amida Care Medicaid |
$73.78
|
| Rate for Payer: Cash Price |
$88.97
|
| Rate for Payer: Cash Price |
$88.97
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$88.97
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$41.48
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$47.70
|
| Rate for Payer: Elderplan Medicare Advantage |
$88.97
|
| Rate for Payer: EmblemHealth Commercial |
$88.97
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$7,378.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$73.78
|
| Rate for Payer: Fidelis Essential Plan QHP |
$73.78
|
| Rate for Payer: Fidelis Medicare Advantage |
$88.97
|
| Rate for Payer: Fidelis Qualified Health Plan |
$77.47
|
| Rate for Payer: Group Health Inc Commercial |
$88.97
|
| Rate for Payer: Group Health Inc Medicare |
$88.97
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$73.78
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$41.48
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$73.78
|
| Rate for Payer: Healthfirst Essential Plan |
$73.78
|
| Rate for Payer: Healthfirst Medicare Advantage |
$75.63
|
| Rate for Payer: Healthfirst QHP |
$73.78
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$88.97
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$73.78
|
| Rate for Payer: SOMOS Essential |
$73.78
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$53.92
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$71.18
|
| Rate for Payer: Wellcare Medicare |
$84.53
|
|
|
ALTEPLASE 10MG/NS 250ML
|
Facility
IP
|
$52.91
|
|
|
Service Code
|
HCPCS J2997
|
| Hospital Charge Code |
41649541
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$26.46 |
| Max. Negotiated Rate |
$26.46 |
| Rate for Payer: Cash Price |
$88.97
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$26.46
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$26.46
|
|
|
ALTEPLASE 10MG/NS 250ML
|
Facility
OP
|
$52.91
|
|
|
Service Code
|
HCPCS J2997
|
| Hospital Charge Code |
41649541
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$26.46 |
| Max. Negotiated Rate |
$7,378.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$29.10
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$88.97
|
| Rate for Payer: Aetna Government |
$88.97
|
| Rate for Payer: Amida Care Medicaid |
$73.78
|
| Rate for Payer: Cash Price |
$88.97
|
| Rate for Payer: Cash Price |
$88.97
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$88.97
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$26.46
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$30.42
|
| Rate for Payer: Elderplan Medicare Advantage |
$88.97
|
| Rate for Payer: EmblemHealth Commercial |
$88.97
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$7,378.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$73.78
|
| Rate for Payer: Fidelis Essential Plan QHP |
$73.78
|
| Rate for Payer: Fidelis Medicare Advantage |
$88.97
|
| Rate for Payer: Fidelis Qualified Health Plan |
$77.47
|
| Rate for Payer: Group Health Inc Commercial |
$88.97
|
| Rate for Payer: Group Health Inc Medicare |
$88.97
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$73.78
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$26.46
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$73.78
|
| Rate for Payer: Healthfirst Essential Plan |
$73.78
|
| Rate for Payer: Healthfirst Medicare Advantage |
$75.63
|
| Rate for Payer: Healthfirst QHP |
$73.78
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$88.97
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$73.78
|
| Rate for Payer: SOMOS Essential |
$73.78
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$34.39
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$71.18
|
| Rate for Payer: Wellcare Medicare |
$84.53
|
|
|
ALTEPLASE 10ML/NS 250ML
|
Facility
OP
|
$52.91
|
|
|
Service Code
|
HCPCS J2997
|
| Hospital Charge Code |
41659541
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$26.46 |
| Max. Negotiated Rate |
$7,378.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$29.10
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$88.97
|
| Rate for Payer: Aetna Government |
$88.97
|
| Rate for Payer: Amida Care Medicaid |
$73.78
|
| Rate for Payer: Cash Price |
$88.97
|
| Rate for Payer: Cash Price |
$88.97
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$88.97
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$26.46
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$30.42
|
| Rate for Payer: Elderplan Medicare Advantage |
$88.97
|
| Rate for Payer: EmblemHealth Commercial |
$88.97
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$7,378.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$73.78
|
| Rate for Payer: Fidelis Essential Plan QHP |
$73.78
|
| Rate for Payer: Fidelis Medicare Advantage |
$88.97
|
| Rate for Payer: Fidelis Qualified Health Plan |
$77.47
|
| Rate for Payer: Group Health Inc Commercial |
$88.97
|
| Rate for Payer: Group Health Inc Medicare |
$88.97
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$73.78
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$26.46
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$73.78
|
| Rate for Payer: Healthfirst Essential Plan |
$73.78
|
| Rate for Payer: Healthfirst Medicare Advantage |
$75.63
|
| Rate for Payer: Healthfirst QHP |
$73.78
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$88.97
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$73.78
|
| Rate for Payer: SOMOS Essential |
$73.78
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$34.39
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$71.18
|
| Rate for Payer: Wellcare Medicare |
$84.53
|
|
|
ALTEPLASE 10ML/NS 250ML
|
Facility
IP
|
$52.91
|
|
|
Service Code
|
HCPCS J2997
|
| Hospital Charge Code |
41659541
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$26.46 |
| Max. Negotiated Rate |
$26.46 |
| Rate for Payer: Cash Price |
$88.97
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$26.46
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$26.46
|
|
|
ALTEPLASE 2 MG INJ
|
Facility
IP
|
$239.00
|
|
|
Service Code
|
HCPCS J2997
|
| Hospital Charge Code |
41642714
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$119.50 |
| Max. Negotiated Rate |
$119.50 |
| Rate for Payer: Cash Price |
$88.97
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$119.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$119.50
|
|
|
ALTEPLASE 2 MG INJ
|
Facility
IP
|
$239.00
|
|
|
Service Code
|
HCPCS J2997
|
| Hospital Charge Code |
41652714
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$119.50 |
| Max. Negotiated Rate |
$119.50 |
| Rate for Payer: Cash Price |
$88.97
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$119.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$119.50
|
|
|
ALTEPLASE 2 MG INJ
|
Facility
OP
|
$239.00
|
|
|
Service Code
|
HCPCS J2997
|
| Hospital Charge Code |
41652714
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$71.18 |
| Max. Negotiated Rate |
$7,378.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$131.45
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$88.97
|
| Rate for Payer: Aetna Government |
$88.97
|
| Rate for Payer: Amida Care Medicaid |
$73.78
|
| Rate for Payer: Cash Price |
$88.97
|
| Rate for Payer: Cash Price |
$88.97
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$88.97
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$119.50
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$137.42
|
| Rate for Payer: Elderplan Medicare Advantage |
$88.97
|
| Rate for Payer: EmblemHealth Commercial |
$88.97
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$7,378.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$73.78
|
| Rate for Payer: Fidelis Essential Plan QHP |
$73.78
|
| Rate for Payer: Fidelis Medicare Advantage |
$88.97
|
| Rate for Payer: Fidelis Qualified Health Plan |
$77.47
|
| Rate for Payer: Group Health Inc Commercial |
$88.97
|
| Rate for Payer: Group Health Inc Medicare |
$88.97
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$73.78
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$119.50
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$73.78
|
| Rate for Payer: Healthfirst Essential Plan |
$73.78
|
| Rate for Payer: Healthfirst Medicare Advantage |
$75.63
|
| Rate for Payer: Healthfirst QHP |
$73.78
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$88.97
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$73.78
|
| Rate for Payer: SOMOS Essential |
$73.78
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$155.35
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$71.18
|
| Rate for Payer: Wellcare Medicare |
$84.53
|
|
|
ALTEPLASE 2 MG INJ
|
Facility
OP
|
$239.00
|
|
|
Service Code
|
HCPCS J2997
|
| Hospital Charge Code |
41642714
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$71.18 |
| Max. Negotiated Rate |
$7,378.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$131.45
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$88.97
|
| Rate for Payer: Aetna Government |
$88.97
|
| Rate for Payer: Amida Care Medicaid |
$73.78
|
| Rate for Payer: Cash Price |
$88.97
|
| Rate for Payer: Cash Price |
$88.97
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$88.97
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$119.50
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$137.42
|
| Rate for Payer: Elderplan Medicare Advantage |
$88.97
|
| Rate for Payer: EmblemHealth Commercial |
$88.97
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$7,378.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$73.78
|
| Rate for Payer: Fidelis Essential Plan QHP |
$73.78
|
| Rate for Payer: Fidelis Medicare Advantage |
$88.97
|
| Rate for Payer: Fidelis Qualified Health Plan |
$77.47
|
| Rate for Payer: Group Health Inc Commercial |
$88.97
|
| Rate for Payer: Group Health Inc Medicare |
$88.97
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$73.78
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$119.50
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$73.78
|
| Rate for Payer: Healthfirst Essential Plan |
$73.78
|
| Rate for Payer: Healthfirst Medicare Advantage |
$75.63
|
| Rate for Payer: Healthfirst QHP |
$73.78
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$88.97
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$73.78
|
| Rate for Payer: SOMOS Essential |
$73.78
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$155.35
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$71.18
|
| Rate for Payer: Wellcare Medicare |
$84.53
|
|
|
ALTEPLASE 50 MG INJ
|
Facility
OP
|
$239.00
|
|
|
Service Code
|
HCPCS J2997
|
| Hospital Charge Code |
41642080
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$71.18 |
| Max. Negotiated Rate |
$7,378.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$131.45
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$88.97
|
| Rate for Payer: Aetna Government |
$88.97
|
| Rate for Payer: Amida Care Medicaid |
$73.78
|
| Rate for Payer: Cash Price |
$88.97
|
| Rate for Payer: Cash Price |
$88.97
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$88.97
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$119.50
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$137.42
|
| Rate for Payer: Elderplan Medicare Advantage |
$88.97
|
| Rate for Payer: EmblemHealth Commercial |
$88.97
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$7,378.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$73.78
|
| Rate for Payer: Fidelis Essential Plan QHP |
$73.78
|
| Rate for Payer: Fidelis Medicare Advantage |
$88.97
|
| Rate for Payer: Fidelis Qualified Health Plan |
$77.47
|
| Rate for Payer: Group Health Inc Commercial |
$88.97
|
| Rate for Payer: Group Health Inc Medicare |
$88.97
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$73.78
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$119.50
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$73.78
|
| Rate for Payer: Healthfirst Essential Plan |
$73.78
|
| Rate for Payer: Healthfirst Medicare Advantage |
$75.63
|
| Rate for Payer: Healthfirst QHP |
$73.78
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$88.97
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$73.78
|
| Rate for Payer: SOMOS Essential |
$73.78
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$155.35
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$71.18
|
| Rate for Payer: Wellcare Medicare |
$84.53
|
|
|
ALTEPLASE 50 MG INJ
|
Facility
IP
|
$239.00
|
|
|
Service Code
|
HCPCS J2997
|
| Hospital Charge Code |
41642080
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$119.50 |
| Max. Negotiated Rate |
$119.50 |
| Rate for Payer: Cash Price |
$88.97
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$119.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$119.50
|
|
|
ALTEPLASE 50 MG INJ
|
Facility
IP
|
$239.00
|
|
|
Service Code
|
HCPCS J2997
|
| Hospital Charge Code |
41652080
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$119.50 |
| Max. Negotiated Rate |
$119.50 |
| Rate for Payer: Cash Price |
$88.97
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$119.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$119.50
|
|
|
ALTEPLASE 50 MG INJ
|
Facility
OP
|
$239.00
|
|
|
Service Code
|
HCPCS J2997
|
| Hospital Charge Code |
41652080
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$71.18 |
| Max. Negotiated Rate |
$7,378.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$131.45
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$88.97
|
| Rate for Payer: Aetna Government |
$88.97
|
| Rate for Payer: Amida Care Medicaid |
$73.78
|
| Rate for Payer: Cash Price |
$88.97
|
| Rate for Payer: Cash Price |
$88.97
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$88.97
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$119.50
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$137.42
|
| Rate for Payer: Elderplan Medicare Advantage |
$88.97
|
| Rate for Payer: EmblemHealth Commercial |
$88.97
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$7,378.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$73.78
|
| Rate for Payer: Fidelis Essential Plan QHP |
$73.78
|
| Rate for Payer: Fidelis Medicare Advantage |
$88.97
|
| Rate for Payer: Fidelis Qualified Health Plan |
$77.47
|
| Rate for Payer: Group Health Inc Commercial |
$88.97
|
| Rate for Payer: Group Health Inc Medicare |
$88.97
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$73.78
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$119.50
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$73.78
|
| Rate for Payer: Healthfirst Essential Plan |
$73.78
|
| Rate for Payer: Healthfirst Medicare Advantage |
$75.63
|
| Rate for Payer: Healthfirst QHP |
$73.78
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$88.97
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$73.78
|
| Rate for Payer: SOMOS Essential |
$73.78
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$155.35
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$71.18
|
| Rate for Payer: Wellcare Medicare |
$84.53
|
|
|
ALTRX 4 10D 36IDX52OD
|
Facility
OP
|
$8,022.50
|
|
| Hospital Charge Code |
64906071
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$2,807.88 |
| Max. Negotiated Rate |
$6,418.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$4,412.38
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$4,011.25
|
| Rate for Payer: Aetna Government |
$4,011.25
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$6,418.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$5,455.30
|
| Rate for Payer: Group Health Inc Commercial |
$4,011.25
|
| Rate for Payer: Group Health Inc Medicare |
$2,807.88
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4,011.25
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4,011.25
|
|
|
ALTRX 4 10D 36IDX52OD
|
Facility
OP
|
$6,418.00
|
|
| Hospital Charge Code |
40005154
|
|
Hospital Revenue Code
|
279
|
| Min. Negotiated Rate |
$2,246.30 |
| Max. Negotiated Rate |
$5,134.40 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$3,529.90
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3,209.00
|
| Rate for Payer: Aetna Government |
$3,209.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$5,134.40
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$4,364.24
|
| Rate for Payer: Group Health Inc Commercial |
$3,209.00
|
| Rate for Payer: Group Health Inc Medicare |
$2,246.30
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$3,209.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$3,209.00
|
|
