|
DIGOXIN 50 MCG/ML ELIXIR PEDIATRIC
|
Facility
|
OP
|
$0.70
|
|
| Hospital Charge Code |
41654330
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$0.56 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.39
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.35
|
| Rate for Payer: Aetna Government |
$0.35
|
| Rate for Payer: Brighton Health Commercial |
$0.53
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.56
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.48
|
| Rate for Payer: Group Health Inc Commercial |
$0.35
|
| Rate for Payer: Group Health Inc Medicare |
$0.25
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.35
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.35
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.46
|
|
|
DIGOXIN 50 MCG/ML ELIXIR PEDIATRIC
|
Facility
|
OP
|
$0.70
|
|
| Hospital Charge Code |
41644330
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$0.56 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.39
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.35
|
| Rate for Payer: Aetna Government |
$0.35
|
| Rate for Payer: Brighton Health Commercial |
$0.53
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.56
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.48
|
| Rate for Payer: Group Health Inc Commercial |
$0.35
|
| Rate for Payer: Group Health Inc Medicare |
$0.25
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.35
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.35
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.46
|
|
|
DIGOXIN IMMUNE FAB 40 MG IV SOLR [31432]
|
Facility
|
OP
|
$5,518.80
|
|
|
Service Code
|
HCPCS J1162
|
| Hospital Charge Code |
50633012011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,759.40 |
| Max. Negotiated Rate |
$4,872.99 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$3,035.34
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$4,777.44
|
| Rate for Payer: Aetna Government |
$4,777.44
|
| Rate for Payer: Brighton Health Commercial |
$3,311.28
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$4,777.44
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2,759.40
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$3,173.31
|
| Rate for Payer: Elderplan Medicare Advantage |
$4,777.44
|
| Rate for Payer: EmblemHealth Commercial |
$2,759.40
|
| Rate for Payer: Fidelis Medicare Advantage |
$4,777.44
|
| Rate for Payer: Group Health Inc Commercial |
$4,777.44
|
| Rate for Payer: Group Health Inc Medicare |
$4,777.44
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,759.40
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2,759.40
|
| Rate for Payer: Healthfirst Medicare Advantage |
$4,060.82
|
| Rate for Payer: Healthfirst QHP |
$4,777.44
|
| Rate for Payer: Humana Medicare |
$4,872.99
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$4,777.44
|
| Rate for Payer: United Healthcare Medicare Advantage |
$4,777.44
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3,587.22
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$3,821.95
|
|
|
DIGOXIN IMMUNE FAB 40 MG IV SOLR [31432]
|
Facility
|
IP
|
$5,518.80
|
|
|
Service Code
|
HCPCS J1162
|
| Hospital Charge Code |
50633012011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,759.40 |
| Max. Negotiated Rate |
$2,759.40 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,759.40
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2,759.40
|
|
|
DIGOXIN IMMUNE FAB (DIGIBIND) 38 MG INJ
|
Facility
|
OP
|
$1,208.00
|
|
|
Service Code
|
HCPCS J1162
|
| Hospital Charge Code |
41651853
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$604.00 |
| Max. Negotiated Rate |
$5,064.09 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$664.40
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$4,777.44
|
| Rate for Payer: Aetna Government |
$4,777.44
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$3,344.21
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$3,344.21
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$3,344.21
|
| Rate for Payer: Brighton Health Commercial |
$724.80
|
| Rate for Payer: Cash Price |
$4,777.44
|
| Rate for Payer: Cash Price |
$4,777.44
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$4,777.44
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$604.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$694.60
|
| Rate for Payer: Elderplan Medicare Advantage |
$4,777.44
|
| Rate for Payer: EmblemHealth Commercial |
$4,777.44
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$4,777.44
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$4,777.44
|
| Rate for Payer: Fidelis Essential Plan QHP |
$5,016.31
|
| Rate for Payer: Fidelis Medicare Advantage |
$4,777.44
|
| Rate for Payer: Fidelis Qualified Health Plan |
$5,016.31
|
| Rate for Payer: Group Health Inc Commercial |
$4,777.44
|
| Rate for Payer: Group Health Inc Medicare |
$4,777.44
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$604.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$604.00
|
| Rate for Payer: Healthfirst Medicare Advantage |
$4,060.82
|
| Rate for Payer: Healthfirst QHP |
$4,777.44
|
| Rate for Payer: Humana Medicare |
$4,872.99
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$4,777.44
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$5,064.09
|
| Rate for Payer: SOMOS Essential |
$5,064.09
|
| Rate for Payer: United Healthcare Commercial |
$4,597.02
|
| Rate for Payer: United Healthcare Medicare Advantage |
$4,777.44
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$785.20
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$3,821.95
|
| Rate for Payer: Wellcare Medicare |
$4,538.57
|
|
|
DIGOXIN IMMUNE FAB (DIGIBIND) 38 MG INJ
|
Facility
|
IP
|
$1,208.00
|
|
|
Service Code
|
HCPCS J1162
|
| Hospital Charge Code |
41651853
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$604.00 |
| Max. Negotiated Rate |
$604.00 |
| Rate for Payer: Cash Price |
$4,777.44
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$604.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$604.00
|
|
|
DIGOXIN IMMUNE FAB (DIGIBIND) 38 MG INJ
|
Facility
|
IP
|
$1,208.00
|
|
|
Service Code
|
HCPCS J1162
|
| Hospital Charge Code |
41641853
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$604.00 |
| Max. Negotiated Rate |
$604.00 |
| Rate for Payer: Cash Price |
$4,777.44
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$604.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$604.00
|
|
|
DIGOXIN IMMUNE FAB (DIGIBIND) 38 MG INJ
|
Facility
|
OP
|
$1,208.00
|
|
|
Service Code
|
HCPCS J1162
|
| Hospital Charge Code |
41641853
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$604.00 |
| Max. Negotiated Rate |
$5,064.09 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$664.40
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$4,777.44
|
| Rate for Payer: Aetna Government |
$4,777.44
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$3,344.21
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$3,344.21
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$3,344.21
|
| Rate for Payer: Brighton Health Commercial |
$724.80
|
| Rate for Payer: Cash Price |
$4,777.44
|
| Rate for Payer: Cash Price |
$4,777.44
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$4,777.44
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$604.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$694.60
|
| Rate for Payer: Elderplan Medicare Advantage |
$4,777.44
|
| Rate for Payer: EmblemHealth Commercial |
$4,777.44
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$4,777.44
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$4,777.44
|
| Rate for Payer: Fidelis Essential Plan QHP |
$5,016.31
|
| Rate for Payer: Fidelis Medicare Advantage |
$4,777.44
|
| Rate for Payer: Fidelis Qualified Health Plan |
$5,016.31
|
| Rate for Payer: Group Health Inc Commercial |
$4,777.44
|
| Rate for Payer: Group Health Inc Medicare |
$4,777.44
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$604.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$604.00
|
| Rate for Payer: Healthfirst Medicare Advantage |
$4,060.82
|
| Rate for Payer: Healthfirst QHP |
$4,777.44
|
| Rate for Payer: Humana Medicare |
$4,872.99
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$4,777.44
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$5,064.09
|
| Rate for Payer: SOMOS Essential |
$5,064.09
|
| Rate for Payer: United Healthcare Commercial |
$4,597.02
|
| Rate for Payer: United Healthcare Medicare Advantage |
$4,777.44
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$785.20
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$3,821.95
|
| Rate for Payer: Wellcare Medicare |
$4,538.57
|
|
|
DIGOXIN IMMUNE FAB (DIGIFAB) 40 MG INJ
|
Facility
|
IP
|
$8,560.00
|
|
|
Service Code
|
HCPCS J1162
|
| Hospital Charge Code |
41653990
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4,280.00 |
| Max. Negotiated Rate |
$4,280.00 |
| Rate for Payer: Cash Price |
$4,777.44
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4,280.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4,280.00
|
|
|
DIGOXIN IMMUNE FAB (DIGIFAB) 40 MG INJ
|
Facility
|
IP
|
$8,560.00
|
|
|
Service Code
|
HCPCS J1162
|
| Hospital Charge Code |
41643990
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4,280.00 |
| Max. Negotiated Rate |
$4,280.00 |
| Rate for Payer: Cash Price |
$4,777.44
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4,280.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4,280.00
|
|
|
DIGOXIN IMMUNE FAB (DIGIFAB) 40 MG INJ
|
Facility
|
OP
|
$8,560.00
|
|
|
Service Code
|
HCPCS J1162
|
| Hospital Charge Code |
41653990
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,344.21 |
| Max. Negotiated Rate |
$5,564.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$4,708.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$4,777.44
|
| Rate for Payer: Aetna Government |
$4,777.44
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$3,344.21
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$3,344.21
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$3,344.21
|
| Rate for Payer: Brighton Health Commercial |
$5,136.00
|
| Rate for Payer: Cash Price |
$4,777.44
|
| Rate for Payer: Cash Price |
$4,777.44
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$4,777.44
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$4,280.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$4,922.00
|
| Rate for Payer: Elderplan Medicare Advantage |
$4,777.44
|
| Rate for Payer: EmblemHealth Commercial |
$4,777.44
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$4,777.44
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$4,777.44
|
| Rate for Payer: Fidelis Essential Plan QHP |
$5,016.31
|
| Rate for Payer: Fidelis Medicare Advantage |
$4,777.44
|
| Rate for Payer: Fidelis Qualified Health Plan |
$5,016.31
|
| Rate for Payer: Group Health Inc Commercial |
$4,777.44
|
| Rate for Payer: Group Health Inc Medicare |
$4,777.44
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4,280.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4,280.00
|
| Rate for Payer: Healthfirst Medicare Advantage |
$4,060.82
|
| Rate for Payer: Healthfirst QHP |
$4,777.44
|
| Rate for Payer: Humana Medicare |
$4,872.99
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$4,777.44
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$5,064.09
|
| Rate for Payer: SOMOS Essential |
$5,064.09
|
| Rate for Payer: United Healthcare Commercial |
$4,597.02
|
| Rate for Payer: United Healthcare Medicare Advantage |
$4,777.44
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$5,564.00
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$3,821.95
|
| Rate for Payer: Wellcare Medicare |
$4,538.57
|
|
|
DIGOXIN IMMUNE FAB (DIGIFAB) 40 MG INJ
|
Facility
|
OP
|
$8,560.00
|
|
|
Service Code
|
HCPCS J1162
|
| Hospital Charge Code |
41643990
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,344.21 |
| Max. Negotiated Rate |
$5,564.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$4,708.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$4,777.44
|
| Rate for Payer: Aetna Government |
$4,777.44
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$3,344.21
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$3,344.21
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$3,344.21
|
| Rate for Payer: Brighton Health Commercial |
$5,136.00
|
| Rate for Payer: Cash Price |
$4,777.44
|
| Rate for Payer: Cash Price |
$4,777.44
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$4,777.44
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$4,280.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$4,922.00
|
| Rate for Payer: Elderplan Medicare Advantage |
$4,777.44
|
| Rate for Payer: EmblemHealth Commercial |
$4,777.44
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$4,777.44
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$4,777.44
|
| Rate for Payer: Fidelis Essential Plan QHP |
$5,016.31
|
| Rate for Payer: Fidelis Medicare Advantage |
$4,777.44
|
| Rate for Payer: Fidelis Qualified Health Plan |
$5,016.31
|
| Rate for Payer: Group Health Inc Commercial |
$4,777.44
|
| Rate for Payer: Group Health Inc Medicare |
$4,777.44
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4,280.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4,280.00
|
| Rate for Payer: Healthfirst Medicare Advantage |
$4,060.82
|
| Rate for Payer: Healthfirst QHP |
$4,777.44
|
| Rate for Payer: Humana Medicare |
$4,872.99
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$4,777.44
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$5,064.09
|
| Rate for Payer: SOMOS Essential |
$5,064.09
|
| Rate for Payer: United Healthcare Commercial |
$4,597.02
|
| Rate for Payer: United Healthcare Medicare Advantage |
$4,777.44
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$5,564.00
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$3,821.95
|
| Rate for Payer: Wellcare Medicare |
$4,538.57
|
|
|
DIHYDROERGOTAMINE 1 MG/ML INJ
|
Facility
|
IP
|
$55.00
|
|
|
Service Code
|
HCPCS J1110
|
| Hospital Charge Code |
41642950
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$27.50 |
| Max. Negotiated Rate |
$27.50 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$27.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$27.50
|
|
|
DIHYDROERGOTAMINE 1 MG/ML INJ
|
Facility
|
OP
|
$55.00
|
|
|
Service Code
|
HCPCS J1110
|
| Hospital Charge Code |
41642950
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.25 |
| Max. Negotiated Rate |
$47.42 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$30.25
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$47.42
|
| Rate for Payer: Aetna Government |
$47.42
|
| Rate for Payer: Brighton Health Commercial |
$33.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$27.50
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$31.62
|
| Rate for Payer: Group Health Inc Commercial |
$27.50
|
| Rate for Payer: Group Health Inc Medicare |
$19.25
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$27.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$27.50
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$39.34
|
| Rate for Payer: SOMOS Essential |
$39.34
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$35.75
|
|
|
DIHYDROERGOTAMINE 1 MG/ML INJ
|
Facility
|
OP
|
$55.00
|
|
|
Service Code
|
HCPCS J1110
|
| Hospital Charge Code |
41652950
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.25 |
| Max. Negotiated Rate |
$47.42 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$30.25
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$47.42
|
| Rate for Payer: Aetna Government |
$47.42
|
| Rate for Payer: Brighton Health Commercial |
$33.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$27.50
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$31.62
|
| Rate for Payer: Group Health Inc Commercial |
$27.50
|
| Rate for Payer: Group Health Inc Medicare |
$19.25
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$27.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$27.50
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$39.34
|
| Rate for Payer: SOMOS Essential |
$39.34
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$35.75
|
|
|
DIHYDROERGOTAMINE 1 MG/ML INJ
|
Facility
|
IP
|
$55.00
|
|
|
Service Code
|
HCPCS J1110
|
| Hospital Charge Code |
41652950
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$27.50 |
| Max. Negotiated Rate |
$27.50 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$27.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$27.50
|
|
|
DILANTIN QUANTITATION
|
Facility
|
IP
|
$33.13
|
|
|
Service Code
|
HCPCS 80185
|
| Hospital Charge Code |
40602020
|
|
Hospital Revenue Code
|
301
|
| Rate for Payer: Cash Price |
$13.25
|
|
|
DILANTIN QUANTITATION
|
Facility
|
OP
|
$33.13
|
|
|
Service Code
|
HCPCS 80185
|
| Hospital Charge Code |
40602020
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$9.28 |
| Max. Negotiated Rate |
$24.85 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$18.22
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$13.25
|
| Rate for Payer: Aetna Government |
$13.25
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$9.28
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$9.28
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$9.28
|
| Rate for Payer: Brighton Health Commercial |
$24.85
|
| Rate for Payer: Cash Price |
$13.25
|
| Rate for Payer: Cash Price |
$13.25
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$13.25
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$21.09
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$17.84
|
| Rate for Payer: Elderplan Medicare Advantage |
$13.25
|
| Rate for Payer: EmblemHealth Commercial |
$13.25
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$11.26
|
| Rate for Payer: Fidelis Essential Plan QHP |
$11.79
|
| Rate for Payer: Fidelis Medicare Advantage |
$13.25
|
| Rate for Payer: Fidelis Qualified Health Plan |
$11.79
|
| Rate for Payer: Group Health Inc Commercial |
$13.25
|
| Rate for Payer: Group Health Inc Medicare |
$13.25
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$16.56
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$13.25
|
| Rate for Payer: Healthfirst Medicare Advantage |
$13.25
|
| Rate for Payer: Healthfirst QHP |
$13.25
|
| Rate for Payer: Humana Medicare |
$13.52
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$13.25
|
| Rate for Payer: United Healthcare Commercial |
$16.79
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13.25
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$13.25
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$10.60
|
| Rate for Payer: Wellcare Medicare |
$11.92
|
|
|
DILATE URETHRA STRICTURE
|
Facility
|
OP
|
$711.45
|
|
|
Service Code
|
HCPCS 53600
|
| Hospital Charge Code |
30306519
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$200.07 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$780.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$285.81
|
| Rate for Payer: Aetna Government |
$285.81
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$200.07
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$200.07
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$200.07
|
| Rate for Payer: Brighton Health Commercial |
$233.00
|
| Rate for Payer: Cash Price |
$285.81
|
| Rate for Payer: Cash Price |
$285.81
|
| Rate for Payer: Cash Price |
$285.81
|
| Rate for Payer: Cash Price |
$285.81
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$285.81
|
| 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: Elderplan Medicare Advantage |
$285.81
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$242.94
|
| Rate for Payer: Fidelis Essential Plan QHP |
$254.37
|
| Rate for Payer: Fidelis Medicare Advantage |
$285.81
|
| Rate for Payer: Fidelis Qualified Health Plan |
$254.37
|
| 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 |
$355.72
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$285.81
|
| Rate for Payer: Healthfirst Medicare Advantage |
$242.94
|
| Rate for Payer: Healthfirst QHP |
$285.81
|
| Rate for Payer: Humana Medicare |
$291.53
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$285.81
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$285.81
|
| Rate for Payer: United Healthcare Commercial |
$222.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$285.81
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$285.81
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$228.65
|
| Rate for Payer: Wellcare Medicare |
$271.52
|
|
|
DILATE URETHRA STRICTURE
|
Facility
|
IP
|
$711.45
|
|
|
Service Code
|
HCPCS 53600
|
| Hospital Charge Code |
30306519
|
|
Hospital Revenue Code
|
510
|
| Rate for Payer: Cash Price |
$285.81
|
|
|
DILATION OF SALIVARY DUCT
|
Facility
|
OP
|
$4,086.83
|
|
|
Service Code
|
HCPCS 42650
|
| Hospital Charge Code |
30303076
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$222.00 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$780.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,763.60
|
| Rate for Payer: Aetna Government |
$1,763.60
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$1,234.52
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$1,234.52
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$1,234.52
|
| Rate for Payer: Brighton Health Commercial |
$233.00
|
| Rate for Payer: Cash Price |
$1,763.60
|
| Rate for Payer: Cash Price |
$1,763.60
|
| Rate for Payer: Cash Price |
$1,763.60
|
| Rate for Payer: Cash Price |
$1,763.60
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,763.60
|
| 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: Elderplan Medicare Advantage |
$1,763.60
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$1,499.06
|
| Rate for Payer: Fidelis Essential Plan QHP |
$1,569.60
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,763.60
|
| Rate for Payer: Fidelis Qualified Health Plan |
$1,569.60
|
| 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 |
$2,043.42
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,763.60
|
| Rate for Payer: Healthfirst Medicare Advantage |
$1,499.06
|
| Rate for Payer: Healthfirst QHP |
$1,763.60
|
| Rate for Payer: Humana Medicare |
$1,798.87
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$1,763.60
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,763.60
|
| Rate for Payer: United Healthcare Commercial |
$222.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,763.60
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,763.60
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$1,410.88
|
| Rate for Payer: Wellcare Medicare |
$1,675.42
|
|
|
DILATION OF SALIVARY DUCT
|
Facility
|
IP
|
$4,086.83
|
|
|
Service Code
|
HCPCS 42650
|
| Hospital Charge Code |
30303076
|
|
Hospital Revenue Code
|
510
|
| Rate for Payer: Cash Price |
$1,763.60
|
|
|
DILATOR, 18CM, FH 0.3MM ST
|
Facility
|
OP
|
$532.50
|
|
| Hospital Charge Code |
64905457
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$186.38 |
| Max. Negotiated Rate |
$426.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$292.88
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$266.25
|
| Rate for Payer: Aetna Government |
$266.25
|
| Rate for Payer: Brighton Health Commercial |
$399.38
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$426.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$362.10
|
| Rate for Payer: Group Health Inc Commercial |
$266.25
|
| Rate for Payer: Group Health Inc Medicare |
$186.38
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$266.25
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$266.25
|
|
|
DILATOR BALLOON CRE 6-8MM 8CM F/G
|
Facility
|
OP
|
$406.00
|
|
| Hospital Charge Code |
40209790
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$142.10 |
| Max. Negotiated Rate |
$324.80 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$223.30
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$203.00
|
| Rate for Payer: Aetna Government |
$203.00
|
| Rate for Payer: Brighton Health Commercial |
$304.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$324.80
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$276.08
|
| Rate for Payer: Group Health Inc Commercial |
$203.00
|
| Rate for Payer: Group Health Inc Medicare |
$142.10
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$203.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$203.00
|
|
|
DILATOR NOTTINGHAM 6-12FR
|
Facility
|
OP
|
$317.75
|
|
| Hospital Charge Code |
64903080
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$111.21 |
| Max. Negotiated Rate |
$254.20 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$174.76
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$158.88
|
| Rate for Payer: Aetna Government |
$158.88
|
| Rate for Payer: Brighton Health Commercial |
$238.31
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$254.20
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$216.07
|
| Rate for Payer: Group Health Inc Commercial |
$158.88
|
| Rate for Payer: Group Health Inc Medicare |
$111.21
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$158.88
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$158.88
|
|
