|
AMOXICILLIN-CLAVULANATE 500 MG TAB
|
Facility
OP
|
$2.00
|
|
| Hospital Charge Code |
41640297
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.70 |
| Max. Negotiated Rate |
$1.60 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.10
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.00
|
| Rate for Payer: Aetna Government |
$1.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.60
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.36
|
| Rate for Payer: Group Health Inc Commercial |
$1.00
|
| Rate for Payer: Group Health Inc Medicare |
$0.70
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.30
|
|
|
AMOXICILLIN-CLAVULANATE 500 MG TAB
|
Facility
OP
|
$2.00
|
|
| Hospital Charge Code |
41650297
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.70 |
| Max. Negotiated Rate |
$1.60 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.10
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.00
|
| Rate for Payer: Aetna Government |
$1.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.60
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.36
|
| Rate for Payer: Group Health Inc Commercial |
$1.00
|
| Rate for Payer: Group Health Inc Medicare |
$0.70
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.30
|
|
|
AMOXICILLIN-CLAVULANATE 875 MG TAB
|
Facility
OP
|
$2.00
|
|
| Hospital Charge Code |
41641698
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.70 |
| Max. Negotiated Rate |
$1.60 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.10
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.00
|
| Rate for Payer: Aetna Government |
$1.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.60
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.36
|
| Rate for Payer: Group Health Inc Commercial |
$1.00
|
| Rate for Payer: Group Health Inc Medicare |
$0.70
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.30
|
|
|
AMOXICILLIN-CLAVULANATE 875 MG TAB
|
Facility
OP
|
$2.00
|
|
| Hospital Charge Code |
41651698
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.70 |
| Max. Negotiated Rate |
$1.60 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.10
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.00
|
| Rate for Payer: Aetna Government |
$1.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.60
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.36
|
| Rate for Payer: Group Health Inc Commercial |
$1.00
|
| Rate for Payer: Group Health Inc Medicare |
$0.70
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.30
|
|
|
AMPHETAMINE CONFIRMATION, UR
|
Facility
OP
|
$107.50
|
|
|
Service Code
|
HCPCS 80324
|
| Hospital Charge Code |
40609016
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$86.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$59.12
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.01
|
| Rate for Payer: Aetna Government |
$0.01
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$86.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$73.10
|
| Rate for Payer: Group Health Inc Commercial |
$53.75
|
| Rate for Payer: Group Health Inc Medicare |
$37.62
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$53.75
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$53.75
|
|
|
AMPHETAMINE SCREEN, URINE
|
Facility
OP
|
$107.50
|
|
|
Service Code
|
HCPCS 80324
|
| Hospital Charge Code |
40609013
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$86.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$59.12
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.01
|
| Rate for Payer: Aetna Government |
$0.01
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$86.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$73.10
|
| Rate for Payer: Group Health Inc Commercial |
$53.75
|
| Rate for Payer: Group Health Inc Medicare |
$37.62
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$53.75
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$53.75
|
|
|
AMPHETAMINE_SCREEN, URINE
|
Facility
OP
|
$107.50
|
|
|
Service Code
|
HCPCS 80324
|
| Hospital Charge Code |
40609842
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$86.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$59.12
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.01
|
| Rate for Payer: Aetna Government |
$0.01
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$86.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$73.10
|
| Rate for Payer: Group Health Inc Commercial |
$53.75
|
| Rate for Payer: Group Health Inc Medicare |
$37.62
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$53.75
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$53.75
|
|
|
AMPHETAMINES, URINE
|
Facility
OP
|
$107.50
|
|
|
Service Code
|
HCPCS 80324
|
| Hospital Charge Code |
40608161
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$86.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$59.12
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.01
|
| Rate for Payer: Aetna Government |
$0.01
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$86.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$73.10
|
| Rate for Payer: Group Health Inc Commercial |
$53.75
|
| Rate for Payer: Group Health Inc Medicare |
$37.62
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$53.75
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$53.75
|
|
|
AMPHOTERICIN B INJ
|
Facility
OP
|
$3.00
|
|
|
Service Code
|
HCPCS J0285
|
| Hospital Charge Code |
41654263
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.05 |
| Max. Negotiated Rate |
$42.65 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.65
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$42.65
|
| Rate for Payer: Aetna Government |
$42.65
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.50
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.72
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$37.51
|
| Rate for Payer: Group Health Inc Commercial |
$1.50
|
| Rate for Payer: Group Health Inc Medicare |
$1.05
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.50
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$41.67
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$40.89
|
| Rate for Payer: SOMOS Essential |
$40.89
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.95
|
|
|
AMPHOTERICIN B INJ
|
Facility
OP
|
$3.00
|
|
|
Service Code
|
HCPCS J0285
|
| Hospital Charge Code |
41644263
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.05 |
| Max. Negotiated Rate |
$42.65 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.65
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$42.65
|
| Rate for Payer: Aetna Government |
$42.65
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.50
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.72
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$37.51
|
| Rate for Payer: Group Health Inc Commercial |
$1.50
|
| Rate for Payer: Group Health Inc Medicare |
$1.05
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.50
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$41.67
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$40.89
|
| Rate for Payer: SOMOS Essential |
$40.89
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.95
|
|
|
AMPHOTERICIN B INJ
|
Facility
IP
|
$3.00
|
|
|
Service Code
|
HCPCS J0285
|
| Hospital Charge Code |
41654263
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$1.50 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.50
|
|
|
AMPHOTERICIN B INJ
|
Facility
IP
|
$3.00
|
|
|
Service Code
|
HCPCS J0285
|
| Hospital Charge Code |
41644263
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$1.50 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.50
|
|
|
AMPHOTERICIN B LIPOSOMAL 1 MG/ML INJ NEO
|
Facility
OP
|
$1.00
|
|
| Hospital Charge Code |
41643813
|
|
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
|
|
|
AMPHOTERICIN B LIPOSOMAL 1 MG/ML INJ NEO
|
Facility
OP
|
$1.00
|
|
| Hospital Charge Code |
41653813
|
|
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
|
|
|
AMPHOTERICIN B LIPOSOMAL INJ
|
Facility
IP
|
$62.01
|
|
|
Service Code
|
HCPCS J0289
|
| Hospital Charge Code |
41654693
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$31.00 |
| Max. Negotiated Rate |
$31.00 |
| Rate for Payer: Cash Price |
$26.66
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$31.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$31.00
|
|
|
AMPHOTERICIN B LIPOSOMAL INJ
|
Facility
OP
|
$62.01
|
|
|
Service Code
|
HCPCS J0289
|
| Hospital Charge Code |
41644693
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.33 |
| Max. Negotiated Rate |
$40.31 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$34.11
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$26.66
|
| Rate for Payer: Aetna Government |
$26.66
|
| Rate for Payer: Cash Price |
$26.66
|
| Rate for Payer: Cash Price |
$26.66
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$26.66
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$31.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$35.66
|
| Rate for Payer: Elderplan Medicare Advantage |
$26.66
|
| Rate for Payer: EmblemHealth Commercial |
$26.66
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$26.66
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$26.66
|
| Rate for Payer: Fidelis Essential Plan QHP |
$27.99
|
| Rate for Payer: Fidelis Medicare Advantage |
$26.66
|
| Rate for Payer: Fidelis Qualified Health Plan |
$27.99
|
| Rate for Payer: Group Health Inc Commercial |
$26.66
|
| Rate for Payer: Group Health Inc Medicare |
$26.66
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$31.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$31.00
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$27.87
|
| Rate for Payer: Healthfirst Medicare Advantage |
$22.66
|
| Rate for Payer: Healthfirst QHP |
$26.66
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$26.66
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$29.34
|
| Rate for Payer: SOMOS Essential |
$29.34
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$40.31
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$21.33
|
| Rate for Payer: Wellcare Medicare |
$25.33
|
|
|
AMPHOTERICIN B LIPOSOMAL INJ
|
Facility
IP
|
$62.01
|
|
|
Service Code
|
HCPCS J0289
|
| Hospital Charge Code |
41644693
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$31.00 |
| Max. Negotiated Rate |
$31.00 |
| Rate for Payer: Cash Price |
$26.66
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$31.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$31.00
|
|
|
AMPHOTERICIN B LIPOSOMAL INJ
|
Facility
OP
|
$62.01
|
|
|
Service Code
|
HCPCS J0289
|
| Hospital Charge Code |
41654693
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.33 |
| Max. Negotiated Rate |
$40.31 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$34.11
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$26.66
|
| Rate for Payer: Aetna Government |
$26.66
|
| Rate for Payer: Cash Price |
$26.66
|
| Rate for Payer: Cash Price |
$26.66
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$26.66
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$31.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$35.66
|
| Rate for Payer: Elderplan Medicare Advantage |
$26.66
|
| Rate for Payer: EmblemHealth Commercial |
$26.66
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$26.66
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$26.66
|
| Rate for Payer: Fidelis Essential Plan QHP |
$27.99
|
| Rate for Payer: Fidelis Medicare Advantage |
$26.66
|
| Rate for Payer: Fidelis Qualified Health Plan |
$27.99
|
| Rate for Payer: Group Health Inc Commercial |
$26.66
|
| Rate for Payer: Group Health Inc Medicare |
$26.66
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$31.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$31.00
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$27.87
|
| Rate for Payer: Healthfirst Medicare Advantage |
$22.66
|
| Rate for Payer: Healthfirst QHP |
$26.66
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$26.66
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$29.34
|
| Rate for Payer: SOMOS Essential |
$29.34
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$40.31
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$21.33
|
| Rate for Payer: Wellcare Medicare |
$25.33
|
|
|
AMPHOTERICIN B LIPOSOME 0.5MG/ML
|
Facility
OP
|
$8.50
|
|
|
Service Code
|
HCPCS J0289
|
| Hospital Charge Code |
41650329
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.25 |
| Max. Negotiated Rate |
$29.34 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$4.68
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$26.66
|
| Rate for Payer: Aetna Government |
$26.66
|
| Rate for Payer: Cash Price |
$26.66
|
| Rate for Payer: Cash Price |
$26.66
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$26.66
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$4.25
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$4.89
|
| Rate for Payer: Elderplan Medicare Advantage |
$26.66
|
| Rate for Payer: EmblemHealth Commercial |
$26.66
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$26.66
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$26.66
|
| Rate for Payer: Fidelis Essential Plan QHP |
$27.99
|
| Rate for Payer: Fidelis Medicare Advantage |
$26.66
|
| Rate for Payer: Fidelis Qualified Health Plan |
$27.99
|
| Rate for Payer: Group Health Inc Commercial |
$26.66
|
| Rate for Payer: Group Health Inc Medicare |
$26.66
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4.25
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4.25
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$27.87
|
| Rate for Payer: Healthfirst Medicare Advantage |
$22.66
|
| Rate for Payer: Healthfirst QHP |
$26.66
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$26.66
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$29.34
|
| Rate for Payer: SOMOS Essential |
$29.34
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$5.52
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$21.33
|
| Rate for Payer: Wellcare Medicare |
$25.33
|
|
|
AMPHOTERICIN B LIPOSOME 0.5MG/ML
|
Facility
OP
|
$8.50
|
|
|
Service Code
|
HCPCS J0289
|
| Hospital Charge Code |
41640329
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.25 |
| Max. Negotiated Rate |
$29.34 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$4.68
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$26.66
|
| Rate for Payer: Aetna Government |
$26.66
|
| Rate for Payer: Cash Price |
$26.66
|
| Rate for Payer: Cash Price |
$26.66
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$26.66
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$4.25
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$4.89
|
| Rate for Payer: Elderplan Medicare Advantage |
$26.66
|
| Rate for Payer: EmblemHealth Commercial |
$26.66
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$26.66
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$26.66
|
| Rate for Payer: Fidelis Essential Plan QHP |
$27.99
|
| Rate for Payer: Fidelis Medicare Advantage |
$26.66
|
| Rate for Payer: Fidelis Qualified Health Plan |
$27.99
|
| Rate for Payer: Group Health Inc Commercial |
$26.66
|
| Rate for Payer: Group Health Inc Medicare |
$26.66
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4.25
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4.25
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$27.87
|
| Rate for Payer: Healthfirst Medicare Advantage |
$22.66
|
| Rate for Payer: Healthfirst QHP |
$26.66
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$26.66
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$29.34
|
| Rate for Payer: SOMOS Essential |
$29.34
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$5.52
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$21.33
|
| Rate for Payer: Wellcare Medicare |
$25.33
|
|
|
AMPHOTERICIN B LIPOSOME 0.5MG/ML
|
Facility
IP
|
$8.50
|
|
|
Service Code
|
HCPCS J0289
|
| Hospital Charge Code |
41640329
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.25 |
| Max. Negotiated Rate |
$4.25 |
| Rate for Payer: Cash Price |
$26.66
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4.25
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4.25
|
|
|
AMPHOTERICIN B LIPOSOME 0.5MG/ML
|
Facility
IP
|
$8.50
|
|
|
Service Code
|
HCPCS J0289
|
| Hospital Charge Code |
41650329
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.25 |
| Max. Negotiated Rate |
$4.25 |
| Rate for Payer: Cash Price |
$26.66
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4.25
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4.25
|
|
|
AMPICILLIN 1000 MG INJ
|
Facility
OP
|
$2.74
|
|
|
Service Code
|
HCPCS J0290
|
| Hospital Charge Code |
41644180
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.70 |
| Max. Negotiated Rate |
$1.78 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.51
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.81
|
| Rate for Payer: Aetna Government |
$0.81
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.37
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.58
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$0.70
|
| Rate for Payer: Group Health Inc Commercial |
$1.37
|
| Rate for Payer: Group Health Inc Medicare |
$0.96
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.37
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.37
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$0.78
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$1.06
|
| Rate for Payer: SOMOS Essential |
$1.06
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.78
|
|
|
AMPICILLIN 1000 MG INJ
|
Facility
IP
|
$2.74
|
|
|
Service Code
|
HCPCS J0290
|
| Hospital Charge Code |
41654180
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.37 |
| Max. Negotiated Rate |
$1.37 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.37
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.37
|
|
|
AMPICILLIN 1000 MG INJ
|
Facility
IP
|
$2.74
|
|
|
Service Code
|
HCPCS J0290
|
| Hospital Charge Code |
41644180
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.37 |
| Max. Negotiated Rate |
$1.37 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.37
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.37
|
|
