|
FOLEY CAT 20 FR 30CC 2-WAY
|
Facility
OP
|
$24.45
|
|
| Hospital Charge Code |
40201832
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$8.56 |
| Max. Negotiated Rate |
$19.56 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$13.45
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$12.22
|
| Rate for Payer: Aetna Government |
$12.22
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$19.56
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$16.63
|
| Rate for Payer: Group Health Inc Commercial |
$12.22
|
| Rate for Payer: Group Health Inc Medicare |
$8.56
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$12.22
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$12.22
|
|
|
FOLEY CAT 20 FR 5CC 3-WAY
|
Facility
OP
|
$41.11
|
|
| Hospital Charge Code |
40201838
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$14.39 |
| Max. Negotiated Rate |
$32.89 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$22.61
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$20.56
|
| Rate for Payer: Aetna Government |
$20.56
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$32.89
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$27.95
|
| Rate for Payer: Group Health Inc Commercial |
$20.56
|
| Rate for Payer: Group Health Inc Medicare |
$14.39
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$20.56
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$20.56
|
|
|
FOLEY CAT 22 FR 30CC 2-WAY
|
Facility
OP
|
$24.45
|
|
| Hospital Charge Code |
40201833
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$8.56 |
| Max. Negotiated Rate |
$19.56 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$13.45
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$12.22
|
| Rate for Payer: Aetna Government |
$12.22
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$19.56
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$16.63
|
| Rate for Payer: Group Health Inc Commercial |
$12.22
|
| Rate for Payer: Group Health Inc Medicare |
$8.56
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$12.22
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$12.22
|
|
|
FOLEY CAT 24 FR 30CC 2-WAY
|
Facility
OP
|
$24.45
|
|
| Hospital Charge Code |
40201834
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$8.56 |
| Max. Negotiated Rate |
$19.56 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$13.45
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$12.22
|
| Rate for Payer: Aetna Government |
$12.22
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$19.56
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$16.63
|
| Rate for Payer: Group Health Inc Commercial |
$12.22
|
| Rate for Payer: Group Health Inc Medicare |
$8.56
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$12.22
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$12.22
|
|
|
FOLEY CAT 24 FR 5CC 3-WAY
|
Facility
OP
|
$41.11
|
|
| Hospital Charge Code |
40201839
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$14.39 |
| Max. Negotiated Rate |
$32.89 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$22.61
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$20.56
|
| Rate for Payer: Aetna Government |
$20.56
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$32.89
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$27.95
|
| Rate for Payer: Group Health Inc Commercial |
$20.56
|
| Rate for Payer: Group Health Inc Medicare |
$14.39
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$20.56
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$20.56
|
|
|
FOLEY CAT 26 FR 30CC 2-WAY
|
Facility
OP
|
$24.45
|
|
| Hospital Charge Code |
40201835
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$8.56 |
| Max. Negotiated Rate |
$19.56 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$13.45
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$12.22
|
| Rate for Payer: Aetna Government |
$12.22
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$19.56
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$16.63
|
| Rate for Payer: Group Health Inc Commercial |
$12.22
|
| Rate for Payer: Group Health Inc Medicare |
$8.56
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$12.22
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$12.22
|
|
|
FOLEY CAT 26 FR 5CC 3-WAY
|
Facility
OP
|
$41.11
|
|
| Hospital Charge Code |
40201840
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$14.39 |
| Max. Negotiated Rate |
$32.89 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$22.61
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$20.56
|
| Rate for Payer: Aetna Government |
$20.56
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$32.89
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$27.95
|
| Rate for Payer: Group Health Inc Commercial |
$20.56
|
| Rate for Payer: Group Health Inc Medicare |
$14.39
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$20.56
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$20.56
|
|
|
FOLEY CATHETER
|
Facility
OP
|
$21.62
|
|
| Hospital Charge Code |
40191940
|
|
Hospital Revenue Code
|
710
|
| Min. Negotiated Rate |
$7.57 |
| Max. Negotiated Rate |
$17.30 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$11.89
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$10.81
|
| Rate for Payer: Aetna Government |
$10.81
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$17.30
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$14.70
|
| Rate for Payer: Group Health Inc Commercial |
$10.81
|
| Rate for Payer: Group Health Inc Medicare |
$7.57
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$10.81
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$10.81
|
|
|
FOLEY CATHETER
|
Facility
OP
|
$21.40
|
|
| Hospital Charge Code |
40207601
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$7.49 |
| Max. Negotiated Rate |
$17.12 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$11.77
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$10.70
|
| Rate for Payer: Aetna Government |
$10.70
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$17.12
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$14.55
|
| Rate for Payer: Group Health Inc Commercial |
$10.70
|
| Rate for Payer: Group Health Inc Medicare |
$7.49
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$10.70
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$10.70
|
|
|
FOLEY CATHETER #20 W/5CC BAG
|
Facility
OP
|
$45.36
|
|
| Hospital Charge Code |
40201820
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$15.88 |
| Max. Negotiated Rate |
$36.29 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$24.95
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$22.68
|
| Rate for Payer: Aetna Government |
$22.68
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$36.29
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$30.84
|
| Rate for Payer: Group Health Inc Commercial |
$22.68
|
| Rate for Payer: Group Health Inc Medicare |
$15.88
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$22.68
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$22.68
|
|
|
FOLEY CATHETERS
|
Facility
OP
|
$19.85
|
|
| Hospital Charge Code |
40000195
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$6.95 |
| Max. Negotiated Rate |
$15.88 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$10.92
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$9.92
|
| Rate for Payer: Aetna Government |
$9.92
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$15.88
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$13.50
|
| Rate for Payer: Group Health Inc Commercial |
$9.92
|
| Rate for Payer: Group Health Inc Medicare |
$6.95
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$9.92
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$9.92
|
|
|
FOLEY CATHETER TRAY
|
Facility
OP
|
$28.35
|
|
| Hospital Charge Code |
40201830
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$9.92 |
| Max. Negotiated Rate |
$22.68 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$15.59
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$14.18
|
| Rate for Payer: Aetna Government |
$14.18
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$22.68
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$19.28
|
| Rate for Payer: Group Health Inc Commercial |
$14.18
|
| Rate for Payer: Group Health Inc Medicare |
$9.92
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$14.18
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$14.18
|
|
|
FOLEY TROCAR
|
Facility
OP
|
$194.48
|
|
| Hospital Charge Code |
64907180
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$68.07 |
| Max. Negotiated Rate |
$155.58 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$106.96
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$97.24
|
| Rate for Payer: Aetna Government |
$97.24
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$155.58
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$132.25
|
| Rate for Payer: Group Health Inc Commercial |
$97.24
|
| Rate for Payer: Group Health Inc Medicare |
$68.07
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$97.24
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$97.24
|
|
|
FOLIC ACID 0.5 MG/ML SOLN
|
Facility
OP
|
$1.00
|
|
| Hospital Charge Code |
41652136
|
|
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
|
|
|
FOLIC ACID 0.5 MG/ML SOLN
|
Facility
OP
|
$1.00
|
|
| Hospital Charge Code |
41642136
|
|
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
|
|
|
FOLIC ACID 1 MG TAB
|
Facility
OP
|
$1.00
|
|
| Hospital Charge Code |
41640257
|
|
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
|
|
|
FOLIC ACID 1 MG TAB
|
Facility
OP
|
$1.00
|
|
| Hospital Charge Code |
41650257
|
|
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
|
|
|
FOLIC ACID 5 MG/ML INJ MDV
|
Facility
OP
|
$37.38
|
|
| Hospital Charge Code |
41643503
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.08 |
| Max. Negotiated Rate |
$29.90 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$20.56
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$18.69
|
| Rate for Payer: Aetna Government |
$18.69
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$29.90
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$25.42
|
| Rate for Payer: Group Health Inc Commercial |
$18.69
|
| Rate for Payer: Group Health Inc Medicare |
$13.08
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$18.69
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$18.69
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$24.30
|
|
|
FOLIC ACID 5 MG/ML INJ MDV
|
Facility
OP
|
$37.38
|
|
| Hospital Charge Code |
41653503
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.08 |
| Max. Negotiated Rate |
$29.90 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$20.56
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$18.69
|
| Rate for Payer: Aetna Government |
$18.69
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$29.90
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$25.42
|
| Rate for Payer: Group Health Inc Commercial |
$18.69
|
| Rate for Payer: Group Health Inc Medicare |
$13.08
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$18.69
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$18.69
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$24.30
|
|
|
FOLIC ACID RIA
|
Facility
OP
|
$36.75
|
|
|
Service Code
|
HCPCS 82746
|
| Hospital Charge Code |
40602370
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$11.76 |
| Max. Negotiated Rate |
$23.37 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$20.21
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$14.70
|
| Rate for Payer: Aetna Government |
$14.70
|
| Rate for Payer: Cash Price |
$14.70
|
| Rate for Payer: Cash Price |
$14.70
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$14.70
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$23.37
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$19.78
|
| Rate for Payer: Elderplan Medicare Advantage |
$14.70
|
| Rate for Payer: EmblemHealth Commercial |
$14.70
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$13.23
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$12.50
|
| Rate for Payer: Fidelis Essential Plan QHP |
$13.08
|
| Rate for Payer: Fidelis Medicare Advantage |
$14.70
|
| Rate for Payer: Fidelis Qualified Health Plan |
$13.08
|
| Rate for Payer: Group Health Inc Commercial |
$14.70
|
| Rate for Payer: Group Health Inc Medicare |
$14.70
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$18.38
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$14.70
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$14.70
|
| Rate for Payer: Healthfirst Medicare Advantage |
$14.70
|
| Rate for Payer: Healthfirst QHP |
$14.70
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$14.70
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$14.70
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$11.76
|
| Rate for Payer: Wellcare Medicare |
$13.23
|
|
|
FOLLOW UP
|
Facility
OP
|
$503.49
|
|
|
Service Code
|
HCPCS 92012
|
| Hospital Charge Code |
42101200
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$52.04 |
| Max. Negotiated Rate |
$276.92 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$276.92
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$152.87
|
| Rate for Payer: Aetna Government |
$152.87
|
| Rate for Payer: Brighton Health Commercial |
$233.00
|
| Rate for Payer: Cash Price |
$152.87
|
| Rate for Payer: Cash Price |
$152.87
|
| Rate for Payer: Cash Price |
$152.87
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$152.87
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$204.58
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$173.89
|
| Rate for Payer: Elderplan Medicare Advantage |
$152.87
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$52.04
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$129.94
|
| Rate for Payer: Fidelis Essential Plan QHP |
$136.05
|
| Rate for Payer: Fidelis Medicare Advantage |
$152.87
|
| Rate for Payer: Fidelis Qualified Health Plan |
$136.05
|
| Rate for Payer: Group Health Inc Commercial |
$250.00
|
| Rate for Payer: Group Health Inc Medicare |
$250.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$251.74
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$152.87
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$57.82
|
| Rate for Payer: Healthfirst Medicare Advantage |
$129.94
|
| Rate for Payer: Healthfirst QHP |
$152.87
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$152.87
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$152.87
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$152.87
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$122.30
|
| Rate for Payer: Wellcare Medicare |
$145.23
|
|
|
FOMEPIZOLE 1000 MG/ML INJ 1.5 ML
|
Facility
OP
|
$26.24
|
|
|
Service Code
|
HCPCS J1451
|
| Hospital Charge Code |
41651892
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.84 |
| Max. Negotiated Rate |
$17.06 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$14.43
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$6.06
|
| Rate for Payer: Aetna Government |
$6.06
|
| Rate for Payer: Cash Price |
$6.06
|
| Rate for Payer: Cash Price |
$6.06
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$6.06
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$13.12
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$15.09
|
| Rate for Payer: Elderplan Medicare Advantage |
$6.06
|
| Rate for Payer: EmblemHealth Commercial |
$6.06
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$6.06
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$6.06
|
| Rate for Payer: Fidelis Essential Plan QHP |
$6.36
|
| Rate for Payer: Fidelis Medicare Advantage |
$6.06
|
| Rate for Payer: Fidelis Qualified Health Plan |
$6.36
|
| Rate for Payer: Group Health Inc Commercial |
$6.06
|
| Rate for Payer: Group Health Inc Medicare |
$6.06
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$13.12
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$13.12
|
| Rate for Payer: Healthfirst Medicare Advantage |
$5.15
|
| Rate for Payer: Healthfirst QHP |
$6.06
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$6.06
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$17.06
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$4.84
|
| Rate for Payer: Wellcare Medicare |
$5.75
|
|
|
FOMEPIZOLE 1000 MG/ML INJ 1.5 ML
|
Facility
IP
|
$26.24
|
|
|
Service Code
|
HCPCS J1451
|
| Hospital Charge Code |
41641892
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.12 |
| Max. Negotiated Rate |
$13.12 |
| Rate for Payer: Cash Price |
$6.06
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$13.12
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$13.12
|
|
|
FOMEPIZOLE 1000 MG/ML INJ 1.5 ML
|
Facility
IP
|
$26.24
|
|
|
Service Code
|
HCPCS J1451
|
| Hospital Charge Code |
41651892
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.12 |
| Max. Negotiated Rate |
$13.12 |
| Rate for Payer: Cash Price |
$6.06
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$13.12
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$13.12
|
|
|
FOMEPIZOLE 1000 MG/ML INJ 1.5 ML
|
Facility
OP
|
$26.24
|
|
|
Service Code
|
HCPCS J1451
|
| Hospital Charge Code |
41641892
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.84 |
| Max. Negotiated Rate |
$17.06 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$14.43
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$6.06
|
| Rate for Payer: Aetna Government |
$6.06
|
| Rate for Payer: Cash Price |
$6.06
|
| Rate for Payer: Cash Price |
$6.06
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$6.06
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$13.12
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$15.09
|
| Rate for Payer: Elderplan Medicare Advantage |
$6.06
|
| Rate for Payer: EmblemHealth Commercial |
$6.06
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$6.06
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$6.06
|
| Rate for Payer: Fidelis Essential Plan QHP |
$6.36
|
| Rate for Payer: Fidelis Medicare Advantage |
$6.06
|
| Rate for Payer: Fidelis Qualified Health Plan |
$6.36
|
| Rate for Payer: Group Health Inc Commercial |
$6.06
|
| Rate for Payer: Group Health Inc Medicare |
$6.06
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$13.12
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$13.12
|
| Rate for Payer: Healthfirst Medicare Advantage |
$5.15
|
| Rate for Payer: Healthfirst QHP |
$6.06
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$6.06
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$17.06
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$4.84
|
| Rate for Payer: Wellcare Medicare |
$5.75
|
|
