|
IMMUNE GLOBULIN (HUMAN) 10 GM/100ML IJ SOLN
|
Facility
|
IP
|
$20.34
|
|
|
Service Code
|
HCPCS J1569
|
| Hospital Charge Code |
0944270005
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.17 |
| Max. Negotiated Rate |
$10.17 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$10.17
|
|
|
IMMUNE GLOBULIN (HUMAN) 10 GM/100ML IJ SOLN
|
Facility
|
OP
|
$20.34
|
|
|
Service Code
|
HCPCS J1561
|
| Hospital Charge Code |
0944270011
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.19 |
| Max. Negotiated Rate |
$4,020.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$11.19
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$48.96
|
| Rate for Payer: Aetna Government |
$48.96
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$90.45
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$90.45
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$40.20
|
| Rate for Payer: Amida Care Medicaid |
$40.20
|
| Rate for Payer: Brighton Health Commercial |
$15.26
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$48.96
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$16.27
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$13.83
|
| Rate for Payer: Elderplan Medicare Advantage |
$48.96
|
| Rate for Payer: EmblemHealth Commercial |
$48.96
|
| Rate for Payer: EmblemHealth Essential Plan 1&2 |
$90.45
|
| Rate for Payer: EmblemHealth Essential Plan 3&4 |
$40.20
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$40.20
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$90.45
|
| Rate for Payer: Fidelis Essential Plan QHP |
$90.45
|
| Rate for Payer: Fidelis Medicare Advantage |
$48.96
|
| Rate for Payer: Fidelis Qualified Health Plan |
$42.21
|
| Rate for Payer: Group Health Inc Commercial |
$48.96
|
| Rate for Payer: Group Health Inc Medicare |
$48.96
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$40.20
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$48.96
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$4,020.00
|
| Rate for Payer: Healthfirst Essential Plan |
$90.45
|
| Rate for Payer: Healthfirst Medicare Advantage |
$41.62
|
| Rate for Payer: Healthfirst QHP |
$65.53
|
| Rate for Payer: Humana Medicare |
$49.94
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$48.96
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$40.20
|
| Rate for Payer: SOMOS Essential |
$90.45
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$90.45
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$44.22
|
| Rate for Payer: United Healthcare Medicaid |
$40.20
|
| Rate for Payer: United Healthcare Medicare Advantage |
$48.96
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$13.22
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$40.20
|
| Rate for Payer: Wellcare Medicare |
$46.51
|
|
|
IMMUNE GLOBULIN (HUMAN) 10 GM/100ML IJ SOLN
|
Facility
|
OP
|
$20.34
|
|
|
Service Code
|
HCPCS J1569
|
| Hospital Charge Code |
0944270005
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.19 |
| Max. Negotiated Rate |
$3,917.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$11.19
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$45.31
|
| Rate for Payer: Aetna Government |
$45.31
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$88.13
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$88.13
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$39.17
|
| Rate for Payer: Amida Care Medicaid |
$39.17
|
| Rate for Payer: Brighton Health Commercial |
$15.26
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$45.31
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$16.27
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$13.83
|
| Rate for Payer: Elderplan Medicare Advantage |
$45.31
|
| Rate for Payer: EmblemHealth Commercial |
$45.31
|
| Rate for Payer: EmblemHealth Essential Plan 1&2 |
$88.13
|
| Rate for Payer: EmblemHealth Essential Plan 3&4 |
$39.17
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$39.17
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$88.13
|
| Rate for Payer: Fidelis Essential Plan QHP |
$88.13
|
| Rate for Payer: Fidelis Medicare Advantage |
$45.31
|
| Rate for Payer: Fidelis Qualified Health Plan |
$41.13
|
| Rate for Payer: Group Health Inc Commercial |
$45.31
|
| Rate for Payer: Group Health Inc Medicare |
$45.31
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$39.17
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$45.31
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$3,917.00
|
| Rate for Payer: Healthfirst Essential Plan |
$88.13
|
| Rate for Payer: Healthfirst Medicare Advantage |
$38.51
|
| Rate for Payer: Healthfirst QHP |
$63.85
|
| Rate for Payer: Humana Medicare |
$46.22
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$45.31
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$39.17
|
| Rate for Payer: SOMOS Essential |
$88.13
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$88.13
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$43.09
|
| Rate for Payer: United Healthcare Medicaid |
$39.17
|
| Rate for Payer: United Healthcare Medicare Advantage |
$45.31
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$13.22
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$39.17
|
| Rate for Payer: Wellcare Medicare |
$43.04
|
|
|
IMMUNE GLOBULIN (HUMAN) 10 GM/100ML IJ SOLN
|
Facility
|
IP
|
$20.34
|
|
|
Service Code
|
HCPCS J1561
|
| Hospital Charge Code |
0944270011
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.17 |
| Max. Negotiated Rate |
$10.17 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$10.17
|
|
|
IMMUNE GLOBULIN (HUMAN) 10 GM/100ML IV SOLN (OCTAGAM)
|
Facility
|
OP
|
$23.31
|
|
|
Service Code
|
HCPCS J1572
|
| Hospital Charge Code |
6898285003
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$12.82 |
| Max. Negotiated Rate |
$3,510.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$12.82
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$55.76
|
| Rate for Payer: Aetna Government |
$55.76
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$78.97
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$78.97
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$35.10
|
| Rate for Payer: Amida Care Medicaid |
$35.10
|
| Rate for Payer: Brighton Health Commercial |
$17.48
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$55.76
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$18.65
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$15.85
|
| Rate for Payer: Elderplan Medicare Advantage |
$55.76
|
| Rate for Payer: EmblemHealth Commercial |
$55.76
|
| Rate for Payer: EmblemHealth Essential Plan 1&2 |
$78.97
|
| Rate for Payer: EmblemHealth Essential Plan 3&4 |
$35.10
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$35.10
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$78.97
|
| Rate for Payer: Fidelis Essential Plan QHP |
$78.97
|
| Rate for Payer: Fidelis Medicare Advantage |
$55.76
|
| Rate for Payer: Fidelis Qualified Health Plan |
$36.85
|
| Rate for Payer: Group Health Inc Commercial |
$55.76
|
| Rate for Payer: Group Health Inc Medicare |
$55.76
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$35.10
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$55.76
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$3,510.00
|
| Rate for Payer: Healthfirst Essential Plan |
$78.97
|
| Rate for Payer: Healthfirst Medicare Advantage |
$47.40
|
| Rate for Payer: Healthfirst QHP |
$57.21
|
| Rate for Payer: Humana Medicare |
$56.88
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$55.76
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$35.10
|
| Rate for Payer: SOMOS Essential |
$78.97
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$78.97
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$38.61
|
| Rate for Payer: United Healthcare Medicaid |
$35.10
|
| Rate for Payer: United Healthcare Medicare Advantage |
$55.76
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$15.15
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$35.10
|
| Rate for Payer: Wellcare Medicare |
$52.97
|
|
|
IMMUNE GLOBULIN (HUMAN) 10 GM/100ML IV SOLN (OCTAGAM)
|
Facility
|
IP
|
$23.31
|
|
|
Service Code
|
HCPCS J1572
|
| Hospital Charge Code |
6898285003
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$11.65 |
| Max. Negotiated Rate |
$11.65 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$11.65
|
|
|
IMMUNE GLOBULIN (HUMAN) 20 GM/200ML IJ SOLN
|
Facility
|
OP
|
$20.34
|
|
|
Service Code
|
HCPCS J1569
|
| Hospital Charge Code |
0944270006
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.19 |
| Max. Negotiated Rate |
$3,917.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$11.19
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$45.31
|
| Rate for Payer: Aetna Government |
$45.31
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$88.13
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$88.13
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$39.17
|
| Rate for Payer: Amida Care Medicaid |
$39.17
|
| Rate for Payer: Brighton Health Commercial |
$15.26
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$45.31
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$16.27
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$13.83
|
| Rate for Payer: Elderplan Medicare Advantage |
$45.31
|
| Rate for Payer: EmblemHealth Commercial |
$45.31
|
| Rate for Payer: EmblemHealth Essential Plan 1&2 |
$88.13
|
| Rate for Payer: EmblemHealth Essential Plan 3&4 |
$39.17
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$39.17
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$88.13
|
| Rate for Payer: Fidelis Essential Plan QHP |
$88.13
|
| Rate for Payer: Fidelis Medicare Advantage |
$45.31
|
| Rate for Payer: Fidelis Qualified Health Plan |
$41.13
|
| Rate for Payer: Group Health Inc Commercial |
$45.31
|
| Rate for Payer: Group Health Inc Medicare |
$45.31
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$39.17
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$45.31
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$3,917.00
|
| Rate for Payer: Healthfirst Essential Plan |
$88.13
|
| Rate for Payer: Healthfirst Medicare Advantage |
$38.51
|
| Rate for Payer: Healthfirst QHP |
$63.85
|
| Rate for Payer: Humana Medicare |
$46.22
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$45.31
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$39.17
|
| Rate for Payer: SOMOS Essential |
$88.13
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$88.13
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$43.09
|
| Rate for Payer: United Healthcare Medicaid |
$39.17
|
| Rate for Payer: United Healthcare Medicare Advantage |
$45.31
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$13.22
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$39.17
|
| Rate for Payer: Wellcare Medicare |
$43.04
|
|
|
IMMUNE GLOBULIN (HUMAN) 20 GM/200ML IJ SOLN
|
Facility
|
IP
|
$20.34
|
|
|
Service Code
|
HCPCS J1561
|
| Hospital Charge Code |
0944270012
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.17 |
| Max. Negotiated Rate |
$10.17 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$10.17
|
|
|
IMMUNE GLOBULIN (HUMAN) 20 GM/200ML IJ SOLN
|
Facility
|
OP
|
$20.34
|
|
|
Service Code
|
HCPCS J1561
|
| Hospital Charge Code |
0944270012
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.19 |
| Max. Negotiated Rate |
$4,020.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$11.19
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$48.96
|
| Rate for Payer: Aetna Government |
$48.96
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$90.45
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$90.45
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$40.20
|
| Rate for Payer: Amida Care Medicaid |
$40.20
|
| Rate for Payer: Brighton Health Commercial |
$15.26
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$48.96
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$16.27
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$13.83
|
| Rate for Payer: Elderplan Medicare Advantage |
$48.96
|
| Rate for Payer: EmblemHealth Commercial |
$48.96
|
| Rate for Payer: EmblemHealth Essential Plan 1&2 |
$90.45
|
| Rate for Payer: EmblemHealth Essential Plan 3&4 |
$40.20
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$40.20
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$90.45
|
| Rate for Payer: Fidelis Essential Plan QHP |
$90.45
|
| Rate for Payer: Fidelis Medicare Advantage |
$48.96
|
| Rate for Payer: Fidelis Qualified Health Plan |
$42.21
|
| Rate for Payer: Group Health Inc Commercial |
$48.96
|
| Rate for Payer: Group Health Inc Medicare |
$48.96
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$40.20
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$48.96
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$4,020.00
|
| Rate for Payer: Healthfirst Essential Plan |
$90.45
|
| Rate for Payer: Healthfirst Medicare Advantage |
$41.62
|
| Rate for Payer: Healthfirst QHP |
$65.53
|
| Rate for Payer: Humana Medicare |
$49.94
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$48.96
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$40.20
|
| Rate for Payer: SOMOS Essential |
$90.45
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$90.45
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$44.22
|
| Rate for Payer: United Healthcare Medicaid |
$40.20
|
| Rate for Payer: United Healthcare Medicare Advantage |
$48.96
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$13.22
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$40.20
|
| Rate for Payer: Wellcare Medicare |
$46.51
|
|
|
IMMUNE GLOBULIN (HUMAN) 20 GM/200ML IJ SOLN
|
Facility
|
IP
|
$20.34
|
|
|
Service Code
|
HCPCS J1569
|
| Hospital Charge Code |
0944270006
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.17 |
| Max. Negotiated Rate |
$10.17 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$10.17
|
|
|
IMMUNE GLOBULIN (HUMAN) 30 GM/300ML IJ SOLN
|
Facility
|
OP
|
$20.34
|
|
|
Service Code
|
HCPCS J1569
|
| Hospital Charge Code |
0944270013
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.19 |
| Max. Negotiated Rate |
$3,917.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$11.19
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$45.31
|
| Rate for Payer: Aetna Government |
$45.31
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$88.13
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$88.13
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$39.17
|
| Rate for Payer: Amida Care Medicaid |
$39.17
|
| Rate for Payer: Brighton Health Commercial |
$15.26
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$45.31
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$16.27
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$13.83
|
| Rate for Payer: Elderplan Medicare Advantage |
$45.31
|
| Rate for Payer: EmblemHealth Commercial |
$45.31
|
| Rate for Payer: EmblemHealth Essential Plan 1&2 |
$88.13
|
| Rate for Payer: EmblemHealth Essential Plan 3&4 |
$39.17
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$39.17
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$88.13
|
| Rate for Payer: Fidelis Essential Plan QHP |
$88.13
|
| Rate for Payer: Fidelis Medicare Advantage |
$45.31
|
| Rate for Payer: Fidelis Qualified Health Plan |
$41.13
|
| Rate for Payer: Group Health Inc Commercial |
$45.31
|
| Rate for Payer: Group Health Inc Medicare |
$45.31
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$39.17
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$45.31
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$3,917.00
|
| Rate for Payer: Healthfirst Essential Plan |
$88.13
|
| Rate for Payer: Healthfirst Medicare Advantage |
$38.51
|
| Rate for Payer: Healthfirst QHP |
$63.85
|
| Rate for Payer: Humana Medicare |
$46.22
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$45.31
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$39.17
|
| Rate for Payer: SOMOS Essential |
$88.13
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$88.13
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$43.09
|
| Rate for Payer: United Healthcare Medicaid |
$39.17
|
| Rate for Payer: United Healthcare Medicare Advantage |
$45.31
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$13.22
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$39.17
|
| Rate for Payer: Wellcare Medicare |
$43.04
|
|
|
IMMUNE GLOBULIN (HUMAN) 30 GM/300ML IJ SOLN
|
Facility
|
IP
|
$20.34
|
|
|
Service Code
|
HCPCS J1569
|
| Hospital Charge Code |
0944270013
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.17 |
| Max. Negotiated Rate |
$10.17 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$10.17
|
|
|
IMMUNE GLOBULIN (HUMAN) 30 GM/300ML IJ SOLN
|
Facility
|
OP
|
$20.34
|
|
|
Service Code
|
HCPCS J1569
|
| Hospital Charge Code |
0944270007
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.19 |
| Max. Negotiated Rate |
$3,917.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$11.19
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$45.31
|
| Rate for Payer: Aetna Government |
$45.31
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$88.13
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$88.13
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$39.17
|
| Rate for Payer: Amida Care Medicaid |
$39.17
|
| Rate for Payer: Brighton Health Commercial |
$15.26
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$45.31
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$16.27
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$13.83
|
| Rate for Payer: Elderplan Medicare Advantage |
$45.31
|
| Rate for Payer: EmblemHealth Commercial |
$45.31
|
| Rate for Payer: EmblemHealth Essential Plan 1&2 |
$88.13
|
| Rate for Payer: EmblemHealth Essential Plan 3&4 |
$39.17
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$39.17
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$88.13
|
| Rate for Payer: Fidelis Essential Plan QHP |
$88.13
|
| Rate for Payer: Fidelis Medicare Advantage |
$45.31
|
| Rate for Payer: Fidelis Qualified Health Plan |
$41.13
|
| Rate for Payer: Group Health Inc Commercial |
$45.31
|
| Rate for Payer: Group Health Inc Medicare |
$45.31
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$39.17
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$45.31
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$3,917.00
|
| Rate for Payer: Healthfirst Essential Plan |
$88.13
|
| Rate for Payer: Healthfirst Medicare Advantage |
$38.51
|
| Rate for Payer: Healthfirst QHP |
$63.85
|
| Rate for Payer: Humana Medicare |
$46.22
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$45.31
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$39.17
|
| Rate for Payer: SOMOS Essential |
$88.13
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$88.13
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$43.09
|
| Rate for Payer: United Healthcare Medicaid |
$39.17
|
| Rate for Payer: United Healthcare Medicare Advantage |
$45.31
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$13.22
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$39.17
|
| Rate for Payer: Wellcare Medicare |
$43.04
|
|
|
IMMUNE GLOBULIN (HUMAN) 30 GM/300ML IJ SOLN
|
Facility
|
IP
|
$20.34
|
|
|
Service Code
|
HCPCS J1569
|
| Hospital Charge Code |
0944270007
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.17 |
| Max. Negotiated Rate |
$10.17 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$10.17
|
|
|
IMMUNE GLOBULIN (HUMAN) 5 GM/100ML IV SOLN (OCTAGAM)
|
Facility
|
OP
|
$11.66
|
|
|
Service Code
|
HCPCS J1568
|
| Hospital Charge Code |
6898284003
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$6.41 |
| Max. Negotiated Rate |
$3,905.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$6.41
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$47.53
|
| Rate for Payer: Aetna Government |
$47.53
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$87.86
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$87.86
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$39.05
|
| Rate for Payer: Amida Care Medicaid |
$39.05
|
| Rate for Payer: Brighton Health Commercial |
$8.74
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$47.53
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$9.32
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$7.93
|
| Rate for Payer: Elderplan Medicare Advantage |
$47.53
|
| Rate for Payer: EmblemHealth Commercial |
$47.53
|
| Rate for Payer: EmblemHealth Essential Plan 1&2 |
$87.86
|
| Rate for Payer: EmblemHealth Essential Plan 3&4 |
$39.05
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$39.05
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$87.86
|
| Rate for Payer: Fidelis Essential Plan QHP |
$87.86
|
| Rate for Payer: Fidelis Medicare Advantage |
$47.53
|
| Rate for Payer: Fidelis Qualified Health Plan |
$41.00
|
| Rate for Payer: Group Health Inc Commercial |
$47.53
|
| Rate for Payer: Group Health Inc Medicare |
$47.53
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$39.05
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$47.53
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$3,905.00
|
| Rate for Payer: Healthfirst Essential Plan |
$87.86
|
| Rate for Payer: Healthfirst Medicare Advantage |
$40.40
|
| Rate for Payer: Healthfirst QHP |
$63.65
|
| Rate for Payer: Humana Medicare |
$48.48
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$47.53
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$39.05
|
| Rate for Payer: SOMOS Essential |
$87.86
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$87.86
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$42.95
|
| Rate for Payer: United Healthcare Medicaid |
$39.05
|
| Rate for Payer: United Healthcare Medicare Advantage |
$47.53
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$7.58
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$39.05
|
| Rate for Payer: Wellcare Medicare |
$45.15
|
|
|
IMMUNE GLOBULIN (HUMAN) 5 GM/100ML IV SOLN (OCTAGAM)
|
Facility
|
IP
|
$11.66
|
|
|
Service Code
|
HCPCS J1568
|
| Hospital Charge Code |
6898284003
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$5.83 |
| Max. Negotiated Rate |
$5.83 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$5.83
|
|
|
IMMUNE GLOBULIN (HUMAN) IM INJ
|
Facility
|
IP
|
$55.11
|
|
|
Service Code
|
HCPCS J1460
|
| Hospital Charge Code |
1353363504
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$27.55 |
| Max. Negotiated Rate |
$27.55 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$27.55
|
|
|
IMMUNE GLOBULIN (HUMAN) IM INJ
|
Facility
|
OP
|
$55.11
|
|
|
Service Code
|
HCPCS J1460
|
| Hospital Charge Code |
1353363504
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$30.31 |
| Max. Negotiated Rate |
$50.01 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$30.31
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$49.03
|
| Rate for Payer: Aetna Government |
$49.03
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$34.32
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$34.32
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$34.32
|
| Rate for Payer: Brighton Health Commercial |
$41.33
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$49.03
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$44.09
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$37.47
|
| Rate for Payer: Elderplan Medicare Advantage |
$49.03
|
| Rate for Payer: EmblemHealth Commercial |
$49.03
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$44.13
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$41.68
|
| Rate for Payer: Fidelis Essential Plan QHP |
$43.64
|
| Rate for Payer: Fidelis Medicare Advantage |
$49.03
|
| Rate for Payer: Fidelis Qualified Health Plan |
$43.64
|
| Rate for Payer: Group Health Inc Commercial |
$49.03
|
| Rate for Payer: Group Health Inc Medicare |
$49.03
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$49.03
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$49.03
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$49.03
|
| Rate for Payer: Healthfirst Medicare Advantage |
$41.68
|
| Rate for Payer: Healthfirst QHP |
$49.03
|
| Rate for Payer: Humana Medicare |
$50.01
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$49.03
|
| Rate for Payer: United Healthcare Medicare Advantage |
$49.03
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$35.82
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$46.58
|
| Rate for Payer: Wellcare Medicare |
$46.58
|
|
|
IMPLANTED TISSUE OF ANY TYPE
|
Facility
|
OP
|
$2,058.62
|
|
|
Service Code
|
EAPG 00455
|
| Min. Negotiated Rate |
$1,495.04 |
| Max. Negotiated Rate |
$2,058.62 |
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$1,495.04
|
| Rate for Payer: Healthfirst Commercial |
$2,058.62
|
|
|
Inborn errors of metabolism
|
Facility
|
IP
|
$127,662.57
|
|
|
Service Code
|
APR-DRG 4234
|
| Min. Negotiated Rate |
$35,549.00 |
| Max. Negotiated Rate |
$127,662.57 |
| Rate for Payer: Affinity Essential Plan 1&2 |
$127,662.57
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$127,662.57
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$56,738.92
|
| Rate for Payer: Amida Care Medicaid |
$56,738.92
|
| Rate for Payer: EmblemHealth Essential Plan 1&2 |
$127,662.57
|
| Rate for Payer: EmblemHealth Essential Plan 3&4 |
$56,738.92
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$56,738.92
|
| Rate for Payer: Fidelis Qualified Health Plan |
$68,086.70
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$56,738.92
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$56,738.92
|
| Rate for Payer: Healthfirst Commercial |
$77,092.00
|
| Rate for Payer: Healthfirst Essential Plan |
$127,662.57
|
| Rate for Payer: Healthfirst QHP |
$35,549.00
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$56,738.92
|
| Rate for Payer: SOMOS Essential |
$127,662.57
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$127,662.57
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$127,662.57
|
| Rate for Payer: United Healthcare Medicaid |
$56,738.92
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$56,738.92
|
|
|
Inborn errors of metabolism
|
Facility
|
IP
|
$49,802.87
|
|
|
Service Code
|
APR-DRG 4232
|
| Min. Negotiated Rate |
$7,571.00 |
| Max. Negotiated Rate |
$49,802.87 |
| Rate for Payer: Affinity Essential Plan 1&2 |
$49,802.87
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$49,802.87
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$22,134.61
|
| Rate for Payer: Amida Care Medicaid |
$22,134.61
|
| Rate for Payer: EmblemHealth Essential Plan 1&2 |
$49,802.87
|
| Rate for Payer: EmblemHealth Essential Plan 3&4 |
$22,134.61
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$22,134.61
|
| Rate for Payer: Fidelis Qualified Health Plan |
$26,561.53
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$22,134.61
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$22,134.61
|
| Rate for Payer: Healthfirst Commercial |
$15,189.00
|
| Rate for Payer: Healthfirst Essential Plan |
$49,802.87
|
| Rate for Payer: Healthfirst QHP |
$7,571.00
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$22,134.61
|
| Rate for Payer: SOMOS Essential |
$49,802.87
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$49,802.87
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$49,802.87
|
| Rate for Payer: United Healthcare Medicaid |
$22,134.61
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$22,134.61
|
|
|
Inborn errors of metabolism
|
Facility
|
IP
|
$60,153.10
|
|
|
Service Code
|
APR-DRG 4233
|
| Min. Negotiated Rate |
$15,363.00 |
| Max. Negotiated Rate |
$60,153.10 |
| Rate for Payer: Affinity Essential Plan 1&2 |
$60,153.10
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$60,153.10
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$26,734.71
|
| Rate for Payer: Amida Care Medicaid |
$26,734.71
|
| Rate for Payer: EmblemHealth Essential Plan 1&2 |
$60,153.10
|
| Rate for Payer: EmblemHealth Essential Plan 3&4 |
$26,734.71
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$26,734.71
|
| Rate for Payer: Fidelis Qualified Health Plan |
$32,081.65
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$26,734.71
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$26,734.71
|
| Rate for Payer: Healthfirst Commercial |
$27,115.00
|
| Rate for Payer: Healthfirst Essential Plan |
$60,153.10
|
| Rate for Payer: Healthfirst QHP |
$15,363.00
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$26,734.71
|
| Rate for Payer: SOMOS Essential |
$60,153.10
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$60,153.10
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$60,153.10
|
| Rate for Payer: United Healthcare Medicaid |
$26,734.71
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$26,734.71
|
|
|
Inborn errors of metabolism
|
Facility
|
IP
|
$42,822.40
|
|
|
Service Code
|
APR-DRG 4231
|
| Min. Negotiated Rate |
$5,546.00 |
| Max. Negotiated Rate |
$42,822.40 |
| Rate for Payer: Affinity Essential Plan 1&2 |
$42,822.40
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$42,822.40
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$19,032.18
|
| Rate for Payer: Amida Care Medicaid |
$19,032.18
|
| Rate for Payer: EmblemHealth Essential Plan 1&2 |
$42,822.40
|
| Rate for Payer: EmblemHealth Essential Plan 3&4 |
$19,032.18
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$19,032.18
|
| Rate for Payer: Fidelis Qualified Health Plan |
$22,838.62
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$19,032.18
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$19,032.18
|
| Rate for Payer: Healthfirst Commercial |
$9,950.00
|
| Rate for Payer: Healthfirst Essential Plan |
$42,822.40
|
| Rate for Payer: Healthfirst QHP |
$5,546.00
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$19,032.18
|
| Rate for Payer: SOMOS Essential |
$42,822.40
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$42,822.40
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$42,822.40
|
| Rate for Payer: United Healthcare Medicaid |
$19,032.18
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$19,032.18
|
|
|
INBORN ERRORS OF METABOLISM
|
Facility
|
OP
|
$194.56
|
|
|
Service Code
|
EAPG 00691
|
| Min. Negotiated Rate |
$141.17 |
| Max. Negotiated Rate |
$194.56 |
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$141.17
|
| Rate for Payer: Healthfirst Commercial |
$194.56
|
|
|
INCIDENTAL INTRAOPERATIVE PROCEDURES
|
Facility
|
OP
|
$2,143.04
|
|
|
Service Code
|
EAPG 02008
|
| Min. Negotiated Rate |
$2,143.04 |
| Max. Negotiated Rate |
$2,143.04 |
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$2,143.04
|
|
