|
ELECTROPLAST 4
|
Facility
|
OP
|
$12.05
|
|
| Hospital Charge Code |
40201464
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$4.22 |
| Max. Negotiated Rate |
$9.64 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$6.63
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$6.02
|
| Rate for Payer: Aetna Government |
$6.02
|
| Rate for Payer: Brighton Health Commercial |
$9.04
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$9.64
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$8.19
|
| Rate for Payer: Group Health Inc Commercial |
$6.02
|
| Rate for Payer: Group Health Inc Medicare |
$4.22
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$6.02
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$6.02
|
|
|
ELETRIPTAN 40 MG TAB
|
Facility
|
OP
|
$49.00
|
|
| Hospital Charge Code |
41644367
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.15 |
| Max. Negotiated Rate |
$39.20 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$26.95
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$24.50
|
| Rate for Payer: Aetna Government |
$24.50
|
| Rate for Payer: Brighton Health Commercial |
$36.75
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$39.20
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$33.32
|
| Rate for Payer: Group Health Inc Commercial |
$24.50
|
| Rate for Payer: Group Health Inc Medicare |
$17.15
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$24.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$24.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$31.85
|
|
|
ELETRIPTAN 40 MG TAB
|
Facility
|
OP
|
$49.00
|
|
| Hospital Charge Code |
41654367
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.15 |
| Max. Negotiated Rate |
$39.20 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$26.95
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$24.50
|
| Rate for Payer: Aetna Government |
$24.50
|
| Rate for Payer: Brighton Health Commercial |
$36.75
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$39.20
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$33.32
|
| Rate for Payer: Group Health Inc Commercial |
$24.50
|
| Rate for Payer: Group Health Inc Medicare |
$17.15
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$24.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$24.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$31.85
|
|
|
ELETRIPTAN HYDROBROMIDE 40 MG PO TABS [34684]
|
Facility
|
OP
|
$61.39
|
|
|
Service Code
|
NDC 00378428808
|
| Hospital Charge Code |
00378428808
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.49 |
| Max. Negotiated Rate |
$49.11 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$33.77
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$30.70
|
| Rate for Payer: Aetna Government |
$30.70
|
| Rate for Payer: Brighton Health Commercial |
$46.04
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$49.11
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$41.75
|
| Rate for Payer: Group Health Inc Commercial |
$30.70
|
| Rate for Payer: Group Health Inc Medicare |
$21.49
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$30.70
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$30.70
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$39.90
|
|
|
ELETRIPTAN HYDROBROMIDE 40 MG PO TABS [34684]
|
Facility
|
OP
|
$61.39
|
|
|
Service Code
|
NDC 00378428885
|
| Hospital Charge Code |
00378428885
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.49 |
| Max. Negotiated Rate |
$49.11 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$33.77
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$30.70
|
| Rate for Payer: Aetna Government |
$30.70
|
| Rate for Payer: Brighton Health Commercial |
$46.04
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$49.11
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$41.75
|
| Rate for Payer: Group Health Inc Commercial |
$30.70
|
| Rate for Payer: Group Health Inc Medicare |
$21.49
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$30.70
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$30.70
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$39.90
|
|
|
ELETRIPTAN HYDROBROMIDE 40 MG PO TABS [34684]
|
Facility
|
OP
|
$96.92
|
|
|
Service Code
|
NDC 00049234045
|
| Hospital Charge Code |
00049234045
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$33.92 |
| Max. Negotiated Rate |
$77.54 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$53.31
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$48.46
|
| Rate for Payer: Aetna Government |
$48.46
|
| Rate for Payer: Brighton Health Commercial |
$72.69
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$77.54
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$65.91
|
| Rate for Payer: Group Health Inc Commercial |
$48.46
|
| Rate for Payer: Group Health Inc Medicare |
$33.92
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$48.46
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$48.46
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$63.00
|
|
|
ELETRIPTAN HYDROBROMIDE 40 MG PO TABS [34684]
|
Facility
|
OP
|
$61.46
|
|
|
Service Code
|
NDC 27241004011
|
| Hospital Charge Code |
27241004011
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.51 |
| Max. Negotiated Rate |
$49.17 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$33.80
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$30.73
|
| Rate for Payer: Aetna Government |
$30.73
|
| Rate for Payer: Brighton Health Commercial |
$46.10
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$49.17
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$41.79
|
| Rate for Payer: Group Health Inc Commercial |
$30.73
|
| Rate for Payer: Group Health Inc Medicare |
$21.51
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$30.73
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$30.73
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$39.95
|
|
|
ELEV BP PLAN OF CARE DOCD
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
HCPCS 0513F
|
| Hospital Charge Code |
30300377
|
|
Hospital Revenue Code
|
969
|
| Max. Negotiated Rate |
$0.01 |
| 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: Brighton Health Commercial |
$0.01
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.01
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.01
|
| 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
|
|
|
ELLA 30 MG TAB
|
Facility
|
OP
|
$34.46
|
|
| Hospital Charge Code |
41648031
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.06 |
| Max. Negotiated Rate |
$27.57 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$18.95
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$17.23
|
| Rate for Payer: Aetna Government |
$17.23
|
| Rate for Payer: Brighton Health Commercial |
$25.84
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$27.57
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$23.43
|
| Rate for Payer: Group Health Inc Commercial |
$17.23
|
| Rate for Payer: Group Health Inc Medicare |
$12.06
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$17.23
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$17.23
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$22.40
|
|
|
ELLA 30MG TAB
|
Facility
|
OP
|
$34.46
|
|
| Hospital Charge Code |
41658031
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.06 |
| Max. Negotiated Rate |
$27.57 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$18.95
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$17.23
|
| Rate for Payer: Aetna Government |
$17.23
|
| Rate for Payer: Brighton Health Commercial |
$25.84
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$27.57
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$23.43
|
| Rate for Payer: Group Health Inc Commercial |
$17.23
|
| Rate for Payer: Group Health Inc Medicare |
$12.06
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$17.23
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$17.23
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$22.40
|
|
|
ELOTUZUMAB 300MG/12ML INJECTION
|
Facility
|
IP
|
$15.48
|
|
|
Service Code
|
HCPCS J9176
|
| Hospital Charge Code |
41657834
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.74 |
| Max. Negotiated Rate |
$7.74 |
| Rate for Payer: Cash Price |
$7.38
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$7.74
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$7.74
|
|
|
ELOTUZUMAB 300MG/12ML INJECTION
|
Facility
|
OP
|
$15.48
|
|
|
Service Code
|
HCPCS J9176
|
| Hospital Charge Code |
41657834
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.17 |
| Max. Negotiated Rate |
$10.06 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$8.51
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$7.38
|
| Rate for Payer: Aetna Government |
$7.38
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$5.17
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$5.17
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$5.17
|
| Rate for Payer: Brighton Health Commercial |
$9.29
|
| Rate for Payer: Cash Price |
$7.38
|
| Rate for Payer: Cash Price |
$7.38
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$7.38
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$7.74
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$8.90
|
| Rate for Payer: Elderplan Medicare Advantage |
$7.38
|
| Rate for Payer: EmblemHealth Commercial |
$7.38
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$7.38
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$7.38
|
| Rate for Payer: Fidelis Essential Plan QHP |
$7.75
|
| Rate for Payer: Fidelis Medicare Advantage |
$7.38
|
| Rate for Payer: Fidelis Qualified Health Plan |
$7.75
|
| Rate for Payer: Group Health Inc Commercial |
$7.38
|
| Rate for Payer: Group Health Inc Medicare |
$7.38
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$7.74
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$7.74
|
| Rate for Payer: Healthfirst Medicare Advantage |
$6.27
|
| Rate for Payer: Healthfirst QHP |
$7.38
|
| Rate for Payer: Humana Medicare |
$7.53
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$7.38
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$7.85
|
| Rate for Payer: SOMOS Essential |
$7.85
|
| Rate for Payer: United Healthcare Commercial |
$7.06
|
| Rate for Payer: United Healthcare Medicare Advantage |
$7.38
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$10.06
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$5.90
|
| Rate for Payer: Wellcare Medicare |
$7.01
|
|
|
ELOTUZUMAB 300MG/12ML INJECTION
|
Facility
|
IP
|
$15.48
|
|
|
Service Code
|
HCPCS J9176
|
| Hospital Charge Code |
41647834
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.74 |
| Max. Negotiated Rate |
$7.74 |
| Rate for Payer: Cash Price |
$7.38
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$7.74
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$7.74
|
|
|
ELOTUZUMAB 300MG/12ML INJECTION
|
Facility
|
OP
|
$15.48
|
|
|
Service Code
|
HCPCS J9176
|
| Hospital Charge Code |
41647834
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.17 |
| Max. Negotiated Rate |
$10.06 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$8.51
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$7.38
|
| Rate for Payer: Aetna Government |
$7.38
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$5.17
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$5.17
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$5.17
|
| Rate for Payer: Brighton Health Commercial |
$9.29
|
| Rate for Payer: Cash Price |
$7.38
|
| Rate for Payer: Cash Price |
$7.38
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$7.38
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$7.74
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$8.90
|
| Rate for Payer: Elderplan Medicare Advantage |
$7.38
|
| Rate for Payer: EmblemHealth Commercial |
$7.38
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$7.38
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$7.38
|
| Rate for Payer: Fidelis Essential Plan QHP |
$7.75
|
| Rate for Payer: Fidelis Medicare Advantage |
$7.38
|
| Rate for Payer: Fidelis Qualified Health Plan |
$7.75
|
| Rate for Payer: Group Health Inc Commercial |
$7.38
|
| Rate for Payer: Group Health Inc Medicare |
$7.38
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$7.74
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$7.74
|
| Rate for Payer: Healthfirst Medicare Advantage |
$6.27
|
| Rate for Payer: Healthfirst QHP |
$7.38
|
| Rate for Payer: Humana Medicare |
$7.53
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$7.38
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$7.85
|
| Rate for Payer: SOMOS Essential |
$7.85
|
| Rate for Payer: United Healthcare Commercial |
$7.06
|
| Rate for Payer: United Healthcare Medicare Advantage |
$7.38
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$10.06
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$5.90
|
| Rate for Payer: Wellcare Medicare |
$7.01
|
|
|
ELOTUZUMAB 400MG/16ML INJECTION
|
Facility
|
OP
|
$15.48
|
|
|
Service Code
|
HCPCS J9176
|
| Hospital Charge Code |
41657835
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.17 |
| Max. Negotiated Rate |
$10.06 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$8.51
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$7.38
|
| Rate for Payer: Aetna Government |
$7.38
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$5.17
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$5.17
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$5.17
|
| Rate for Payer: Brighton Health Commercial |
$9.29
|
| Rate for Payer: Cash Price |
$7.38
|
| Rate for Payer: Cash Price |
$7.38
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$7.38
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$7.74
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$8.90
|
| Rate for Payer: Elderplan Medicare Advantage |
$7.38
|
| Rate for Payer: EmblemHealth Commercial |
$7.38
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$7.38
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$7.38
|
| Rate for Payer: Fidelis Essential Plan QHP |
$7.75
|
| Rate for Payer: Fidelis Medicare Advantage |
$7.38
|
| Rate for Payer: Fidelis Qualified Health Plan |
$7.75
|
| Rate for Payer: Group Health Inc Commercial |
$7.38
|
| Rate for Payer: Group Health Inc Medicare |
$7.38
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$7.74
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$7.74
|
| Rate for Payer: Healthfirst Medicare Advantage |
$6.27
|
| Rate for Payer: Healthfirst QHP |
$7.38
|
| Rate for Payer: Humana Medicare |
$7.53
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$7.38
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$7.85
|
| Rate for Payer: SOMOS Essential |
$7.85
|
| Rate for Payer: United Healthcare Commercial |
$7.06
|
| Rate for Payer: United Healthcare Medicare Advantage |
$7.38
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$10.06
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$5.90
|
| Rate for Payer: Wellcare Medicare |
$7.01
|
|
|
ELOTUZUMAB 400MG/16ML INJECTION
|
Facility
|
IP
|
$15.48
|
|
|
Service Code
|
HCPCS J9176
|
| Hospital Charge Code |
41647835
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.74 |
| Max. Negotiated Rate |
$7.74 |
| Rate for Payer: Cash Price |
$7.38
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$7.74
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$7.74
|
|
|
ELOTUZUMAB 400MG/16ML INJECTION
|
Facility
|
OP
|
$15.48
|
|
|
Service Code
|
HCPCS J9176
|
| Hospital Charge Code |
41647835
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.17 |
| Max. Negotiated Rate |
$10.06 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$8.51
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$7.38
|
| Rate for Payer: Aetna Government |
$7.38
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$5.17
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$5.17
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$5.17
|
| Rate for Payer: Brighton Health Commercial |
$9.29
|
| Rate for Payer: Cash Price |
$7.38
|
| Rate for Payer: Cash Price |
$7.38
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$7.38
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$7.74
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$8.90
|
| Rate for Payer: Elderplan Medicare Advantage |
$7.38
|
| Rate for Payer: EmblemHealth Commercial |
$7.38
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$7.38
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$7.38
|
| Rate for Payer: Fidelis Essential Plan QHP |
$7.75
|
| Rate for Payer: Fidelis Medicare Advantage |
$7.38
|
| Rate for Payer: Fidelis Qualified Health Plan |
$7.75
|
| Rate for Payer: Group Health Inc Commercial |
$7.38
|
| Rate for Payer: Group Health Inc Medicare |
$7.38
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$7.74
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$7.74
|
| Rate for Payer: Healthfirst Medicare Advantage |
$6.27
|
| Rate for Payer: Healthfirst QHP |
$7.38
|
| Rate for Payer: Humana Medicare |
$7.53
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$7.38
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$7.85
|
| Rate for Payer: SOMOS Essential |
$7.85
|
| Rate for Payer: United Healthcare Commercial |
$7.06
|
| Rate for Payer: United Healthcare Medicare Advantage |
$7.38
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$10.06
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$5.90
|
| Rate for Payer: Wellcare Medicare |
$7.01
|
|
|
ELOTUZUMAB 400MG/16ML INJECTION
|
Facility
|
IP
|
$15.48
|
|
|
Service Code
|
HCPCS J9176
|
| Hospital Charge Code |
41657835
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.74 |
| Max. Negotiated Rate |
$7.74 |
| Rate for Payer: Cash Price |
$7.38
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$7.74
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$7.74
|
|
|
ELOTUZUMAB 400 MG IV SOLR [131515]
|
Facility
|
IP
|
$3,499.63
|
|
|
Service Code
|
HCPCS J9176
|
| Hospital Charge Code |
00003452211
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,749.82 |
| Max. Negotiated Rate |
$1,749.82 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,749.82
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,749.82
|
|
|
ELOTUZUMAB 400 MG IV SOLR [131515]
|
Facility
|
OP
|
$3,499.63
|
|
|
Service Code
|
HCPCS J9176
|
| Hospital Charge Code |
00003452211
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5.90 |
| Max. Negotiated Rate |
$2,274.76 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,924.80
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$7.38
|
| Rate for Payer: Aetna Government |
$7.38
|
| Rate for Payer: Brighton Health Commercial |
$2,099.78
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$7.38
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,749.82
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,012.29
|
| Rate for Payer: Elderplan Medicare Advantage |
$7.38
|
| Rate for Payer: EmblemHealth Commercial |
$1,749.82
|
| Rate for Payer: Fidelis Medicare Advantage |
$7.38
|
| Rate for Payer: Group Health Inc Commercial |
$7.38
|
| Rate for Payer: Group Health Inc Medicare |
$7.38
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,749.82
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,749.82
|
| Rate for Payer: Healthfirst Medicare Advantage |
$6.27
|
| Rate for Payer: Healthfirst QHP |
$7.38
|
| Rate for Payer: Humana Medicare |
$7.53
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$7.38
|
| Rate for Payer: United Healthcare Medicare Advantage |
$7.38
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2,274.76
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$5.90
|
|
|
ELVET/COBIC/EMTRICITAB/TENOF
|
Facility
|
OP
|
$156.00
|
|
| Hospital Charge Code |
41656500
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$54.60 |
| Max. Negotiated Rate |
$124.80 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$85.80
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$78.00
|
| Rate for Payer: Aetna Government |
$78.00
|
| Rate for Payer: Brighton Health Commercial |
$117.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$124.80
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$106.08
|
| Rate for Payer: Group Health Inc Commercial |
$78.00
|
| Rate for Payer: Group Health Inc Medicare |
$54.60
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$78.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$78.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$101.40
|
|
|
ELVET/COBIC/EMTRICITAB/TENOF
|
Facility
|
OP
|
$156.00
|
|
| Hospital Charge Code |
41646500
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$54.60 |
| Max. Negotiated Rate |
$124.80 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$85.80
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$78.00
|
| Rate for Payer: Aetna Government |
$78.00
|
| Rate for Payer: Brighton Health Commercial |
$117.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$124.80
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$106.08
|
| Rate for Payer: Group Health Inc Commercial |
$78.00
|
| Rate for Payer: Group Health Inc Medicare |
$54.60
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$78.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$78.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$101.40
|
|
|
ELVIT/COBIC/EMTRIC/TENOF TAB
|
Facility
|
OP
|
$213.62
|
|
| Hospital Charge Code |
41656631
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$74.77 |
| Max. Negotiated Rate |
$170.90 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$117.49
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$106.81
|
| Rate for Payer: Aetna Government |
$106.81
|
| Rate for Payer: Brighton Health Commercial |
$160.22
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$170.90
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$145.26
|
| Rate for Payer: Group Health Inc Commercial |
$106.81
|
| Rate for Payer: Group Health Inc Medicare |
$74.77
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$106.81
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$106.81
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$138.85
|
|
|
ELVIT/COBIC/EMTRIC/TENOF TAB
|
Facility
|
OP
|
$213.62
|
|
| Hospital Charge Code |
41646631
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$74.77 |
| Max. Negotiated Rate |
$170.90 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$117.49
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$106.81
|
| Rate for Payer: Aetna Government |
$106.81
|
| Rate for Payer: Brighton Health Commercial |
$160.22
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$170.90
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$145.26
|
| Rate for Payer: Group Health Inc Commercial |
$106.81
|
| Rate for Payer: Group Health Inc Medicare |
$74.77
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$106.81
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$106.81
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$138.85
|
|
|
ELVITEG-COBIC-EMTRICIT-TENOFAF 150-150-200-10 MG PO TABS [131356]
|
Facility
|
OP
|
$159.25
|
|
|
Service Code
|
NDC 61958190101
|
| Hospital Charge Code |
61958190101
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$55.74 |
| Max. Negotiated Rate |
$127.40 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$87.59
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$79.62
|
| Rate for Payer: Aetna Government |
$79.62
|
| Rate for Payer: Brighton Health Commercial |
$119.44
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$127.40
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$108.29
|
| Rate for Payer: Group Health Inc Commercial |
$79.62
|
| Rate for Payer: Group Health Inc Medicare |
$55.74
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$79.62
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$79.62
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$103.51
|
|
