|
FACTOR_XIII_ACTIVITY
|
Facility
|
IP
|
$40.85
|
|
|
Service Code
|
HCPCS 85290
|
| Hospital Charge Code |
40629861
|
|
Hospital Revenue Code
|
305
|
| Rate for Payer: Cash Price |
$16.34
|
|
|
FACTOR_XIII_ACTIVITY
|
Facility
|
OP
|
$40.85
|
|
|
Service Code
|
HCPCS 85290
|
| Hospital Charge Code |
40629861
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$11.44 |
| Max. Negotiated Rate |
$30.64 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$22.47
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$16.34
|
| Rate for Payer: Aetna Government |
$16.34
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$11.44
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$11.44
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$11.44
|
| Rate for Payer: Brighton Health Commercial |
$30.64
|
| Rate for Payer: Cash Price |
$16.34
|
| Rate for Payer: Cash Price |
$16.34
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$16.34
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$25.97
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$21.98
|
| Rate for Payer: Elderplan Medicare Advantage |
$16.34
|
| Rate for Payer: EmblemHealth Commercial |
$16.34
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$13.89
|
| Rate for Payer: Fidelis Essential Plan QHP |
$14.54
|
| Rate for Payer: Fidelis Medicare Advantage |
$16.34
|
| Rate for Payer: Fidelis Qualified Health Plan |
$14.54
|
| Rate for Payer: Group Health Inc Commercial |
$16.34
|
| Rate for Payer: Group Health Inc Medicare |
$16.34
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$20.42
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$16.34
|
| Rate for Payer: Healthfirst Medicare Advantage |
$16.34
|
| Rate for Payer: Healthfirst QHP |
$16.34
|
| Rate for Payer: Humana Medicare |
$16.67
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$16.34
|
| Rate for Payer: United Healthcare Commercial |
$20.70
|
| Rate for Payer: United Healthcare Medicare Advantage |
$16.34
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$16.34
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$13.07
|
| Rate for Payer: Wellcare Medicare |
$14.71
|
|
|
FALLIUM GA-67
|
Facility
|
OP
|
$17.95
|
|
|
Service Code
|
HCPCS A9556
|
| Hospital Charge Code |
41646584
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$6.28 |
| Max. Negotiated Rate |
$99.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$9.87
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$99.50
|
| Rate for Payer: Aetna Government |
$99.50
|
| Rate for Payer: Brighton Health Commercial |
$13.46
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$14.36
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$12.21
|
| Rate for Payer: Group Health Inc Commercial |
$8.98
|
| Rate for Payer: Group Health Inc Medicare |
$6.28
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$8.98
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$8.98
|
|
|
FALL RISK ASSESSMENT DOCD
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
HCPCS 3288F
|
| Hospital Charge Code |
30307898
|
|
Hospital Revenue Code
|
969
|
| Max. Negotiated Rate |
$2,915.00 |
| 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 |
$2,915.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,477.75
|
| 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
|
|
|
FAMCICLOVIR 500MG CAP
|
Facility
|
OP
|
$8.00
|
|
| Hospital Charge Code |
41657275
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.80 |
| Max. Negotiated Rate |
$6.40 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$4.40
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$4.00
|
| Rate for Payer: Aetna Government |
$4.00
|
| Rate for Payer: Brighton Health Commercial |
$6.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$6.40
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$5.44
|
| Rate for Payer: Group Health Inc Commercial |
$4.00
|
| Rate for Payer: Group Health Inc Medicare |
$2.80
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$5.20
|
|
|
FAMCICLOVIR 500MG CAP
|
Facility
|
OP
|
$8.00
|
|
| Hospital Charge Code |
41647275
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.80 |
| Max. Negotiated Rate |
$6.40 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$4.40
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$4.00
|
| Rate for Payer: Aetna Government |
$4.00
|
| Rate for Payer: Brighton Health Commercial |
$6.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$6.40
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$5.44
|
| Rate for Payer: Group Health Inc Commercial |
$4.00
|
| Rate for Payer: Group Health Inc Medicare |
$2.80
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$5.20
|
|
|
FAMILIAL DYSAUTONOMIA, DNA
|
Facility
|
OP
|
$98.28
|
|
|
Service Code
|
HCPCS 81260
|
| Hospital Charge Code |
40603051
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$27.52 |
| Max. Negotiated Rate |
$78.62 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$54.05
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$39.31
|
| Rate for Payer: Aetna Government |
$39.31
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$27.52
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$27.52
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$27.52
|
| Rate for Payer: Brighton Health Commercial |
$73.71
|
| Rate for Payer: Cash Price |
$39.31
|
| Rate for Payer: Cash Price |
$39.31
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$39.31
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$78.62
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$66.83
|
| Rate for Payer: Elderplan Medicare Advantage |
$39.31
|
| Rate for Payer: EmblemHealth Commercial |
$39.31
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$33.41
|
| Rate for Payer: Fidelis Essential Plan QHP |
$34.99
|
| Rate for Payer: Fidelis Medicare Advantage |
$39.31
|
| Rate for Payer: Fidelis Qualified Health Plan |
$34.99
|
| Rate for Payer: Group Health Inc Commercial |
$39.31
|
| Rate for Payer: Group Health Inc Medicare |
$39.31
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$49.14
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$39.31
|
| Rate for Payer: Healthfirst Medicare Advantage |
$39.31
|
| Rate for Payer: Healthfirst QHP |
$39.31
|
| Rate for Payer: Humana Medicare |
$40.10
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$39.31
|
| Rate for Payer: United Healthcare Commercial |
$35.38
|
| Rate for Payer: United Healthcare Medicare Advantage |
$39.31
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$39.31
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$31.45
|
| Rate for Payer: Wellcare Medicare |
$35.38
|
|
|
FAMILIAL DYSAUTONOMIA, DNA
|
Facility
|
IP
|
$98.28
|
|
|
Service Code
|
HCPCS 81260
|
| Hospital Charge Code |
40603051
|
|
Hospital Revenue Code
|
300
|
| Rate for Payer: Cash Price |
$39.31
|
|
|
FAMILY THERAPY W/O PATIENT
|
Facility
|
IP
|
$397.85
|
|
|
Service Code
|
HCPCS 90846
|
| Hospital Charge Code |
30400083
|
|
Hospital Revenue Code
|
905
|
| Rate for Payer: Cash Price |
$184.38
|
|
|
FAMILY THERAPY W/O PATIENT
|
Facility
|
OP
|
$397.85
|
|
|
Service Code
|
HCPCS 90846
|
| Hospital Charge Code |
30400083
|
|
Hospital Revenue Code
|
905
|
| Min. Negotiated Rate |
$129.07 |
| Max. Negotiated Rate |
$318.28 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$218.82
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$184.38
|
| Rate for Payer: Aetna Government |
$184.38
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$129.07
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$129.07
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$129.07
|
| Rate for Payer: Brighton Health Commercial |
$298.39
|
| Rate for Payer: Carelon Behavioral Health Medicare Advantage |
$184.38
|
| Rate for Payer: Cash Price |
$184.38
|
| Rate for Payer: Cash Price |
$184.38
|
| Rate for Payer: Cash Price |
$184.38
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$184.38
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$318.28
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$270.54
|
| Rate for Payer: Elderplan Medicare Advantage |
$184.38
|
| Rate for Payer: EmblemHealth Commercial |
$184.38
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$156.72
|
| Rate for Payer: Fidelis Essential Plan QHP |
$164.10
|
| Rate for Payer: Fidelis Medicare Advantage |
$184.38
|
| Rate for Payer: Fidelis Qualified Health Plan |
$164.10
|
| Rate for Payer: Group Health Inc Commercial |
$184.38
|
| Rate for Payer: Group Health Inc Medicare |
$184.38
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$198.92
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$184.38
|
| Rate for Payer: Healthfirst Medicare Advantage |
$156.72
|
| Rate for Payer: Healthfirst QHP |
$184.38
|
| Rate for Payer: Humana Medicare |
$188.07
|
| Rate for Payer: Optum Commercial/Medicare |
$143.00
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$184.38
|
| Rate for Payer: United Healthcare Medicare Advantage |
$184.38
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$184.38
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$147.50
|
| Rate for Payer: Wellcare Medicare |
$175.16
|
|
|
FAMILY THERAPY W/PATIENT
|
Facility
|
IP
|
$397.85
|
|
|
Service Code
|
HCPCS 90847
|
| Hospital Charge Code |
30400084
|
|
Hospital Revenue Code
|
905
|
| Rate for Payer: Cash Price |
$184.38
|
|
|
FAMILY THERAPY W/PATIENT
|
Facility
|
OP
|
$397.85
|
|
|
Service Code
|
HCPCS 90847
|
| Hospital Charge Code |
30400084
|
|
Hospital Revenue Code
|
905
|
| Min. Negotiated Rate |
$143.00 |
| Max. Negotiated Rate |
$26,116.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$218.82
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$184.38
|
| Rate for Payer: Aetna Government |
$184.38
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$587.61
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$587.61
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$261.16
|
| Rate for Payer: Amida Care Medicaid |
$261.16
|
| Rate for Payer: Brighton Health Commercial |
$298.39
|
| Rate for Payer: Carelon Behavioral Health HARP/QHP |
$263.54
|
| Rate for Payer: Carelon Behavioral Health Medicare Advantage |
$184.38
|
| Rate for Payer: Cash Price |
$184.38
|
| Rate for Payer: Cash Price |
$184.38
|
| Rate for Payer: Cash Price |
$184.38
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$184.38
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$318.28
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$270.54
|
| Rate for Payer: Elderplan Medicare Advantage |
$184.38
|
| Rate for Payer: EmblemHealth Commercial |
$184.38
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$26,116.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$261.16
|
| Rate for Payer: Fidelis Essential Plan QHP |
$261.16
|
| Rate for Payer: Fidelis Medicare Advantage |
$184.38
|
| Rate for Payer: Fidelis Qualified Health Plan |
$274.22
|
| Rate for Payer: Group Health Inc Commercial |
$184.38
|
| Rate for Payer: Group Health Inc Medicare |
$184.38
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$261.16
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$184.38
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$261.16
|
| Rate for Payer: Healthfirst Essential Plan |
$587.61
|
| Rate for Payer: Healthfirst Medicare Advantage |
$156.72
|
| Rate for Payer: Healthfirst QHP |
$261.16
|
| Rate for Payer: Humana Medicare |
$188.07
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$263.54
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$592.96
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$592.96
|
| Rate for Payer: Optum Commercial/Medicare |
$143.00
|
| Rate for Payer: Optum Medicaid |
$263.54
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$184.38
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$261.16
|
| Rate for Payer: SOMOS Essential |
$587.61
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$587.61
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$287.28
|
| Rate for Payer: United Healthcare Medicaid |
$261.16
|
| Rate for Payer: United Healthcare Medicare Advantage |
$184.38
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$184.38
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$147.50
|
| Rate for Payer: Wellcare Medicare |
$175.16
|
|
|
FAMOTIDINE 10MG ML PED SYRINGE
|
Facility
|
OP
|
$1.03
|
|
| Hospital Charge Code |
41658052
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$0.82 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.57
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.52
|
| Rate for Payer: Aetna Government |
$0.52
|
| Rate for Payer: Brighton Health Commercial |
$0.77
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.82
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.70
|
| Rate for Payer: Group Health Inc Commercial |
$0.52
|
| Rate for Payer: Group Health Inc Medicare |
$0.36
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.52
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.52
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.67
|
|
|
FAMOTIDINE 10MG ML PED SYRINGE
|
Facility
|
OP
|
$1.03
|
|
| Hospital Charge Code |
41648052
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$0.82 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.57
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.52
|
| Rate for Payer: Aetna Government |
$0.52
|
| Rate for Payer: Brighton Health Commercial |
$0.77
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.82
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.70
|
| Rate for Payer: Group Health Inc Commercial |
$0.52
|
| Rate for Payer: Group Health Inc Medicare |
$0.36
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.52
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.52
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.67
|
|
|
FAMOTIDINE 10 MG PO TABS [15065]
|
Facility
|
OP
|
$0.09
|
|
|
Service Code
|
NDC 55111011890
|
| Hospital Charge Code |
55111011890
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.05
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.05
|
| Rate for Payer: Aetna Government |
$0.05
|
| Rate for Payer: Brighton Health Commercial |
$0.07
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.07
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.06
|
| Rate for Payer: Group Health Inc Commercial |
$0.05
|
| Rate for Payer: Group Health Inc Medicare |
$0.03
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.05
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.05
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.06
|
|
|
FAMOTIDINE 10 MG PO TABS [15065]
|
Facility
|
OP
|
$0.30
|
|
|
Service Code
|
NDC 00904552987
|
| Hospital Charge Code |
00904552987
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.24 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.17
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.15
|
| Rate for Payer: Aetna Government |
$0.15
|
| Rate for Payer: Brighton Health Commercial |
$0.23
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.24
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.20
|
| Rate for Payer: Group Health Inc Commercial |
$0.15
|
| Rate for Payer: Group Health Inc Medicare |
$0.11
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.15
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.15
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.20
|
|
|
FAMOTIDINE 10MG TAB
|
Facility
|
OP
|
$0.11
|
|
| Hospital Charge Code |
41648051
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.06
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.06
|
| Rate for Payer: Aetna Government |
$0.06
|
| Rate for Payer: Brighton Health Commercial |
$0.08
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.09
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.07
|
| Rate for Payer: Group Health Inc Commercial |
$0.06
|
| Rate for Payer: Group Health Inc Medicare |
$0.04
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.06
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.06
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.07
|
|
|
FAMOTIDINE 10MG TAB
|
Facility
|
OP
|
$0.11
|
|
| Hospital Charge Code |
41658051
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.06
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.06
|
| Rate for Payer: Aetna Government |
$0.06
|
| Rate for Payer: Brighton Health Commercial |
$0.08
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.09
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.07
|
| Rate for Payer: Group Health Inc Commercial |
$0.06
|
| Rate for Payer: Group Health Inc Medicare |
$0.04
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.06
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.06
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.07
|
|
|
FAMOTIDINE 20MG/50ML PRMX IVPB
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
41656075
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.10 |
| Max. Negotiated Rate |
$3.90 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$3.30
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3.00
|
| Rate for Payer: Aetna Government |
$3.00
|
| Rate for Payer: Brighton Health Commercial |
$3.60
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$3.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$3.45
|
| Rate for Payer: Group Health Inc Commercial |
$3.00
|
| Rate for Payer: Group Health Inc Medicare |
$2.10
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$3.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$3.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3.90
|
|
|
FAMOTIDINE 20MG/50ML PRMX IVPB
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
41646075
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.10 |
| Max. Negotiated Rate |
$3.90 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$3.30
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3.00
|
| Rate for Payer: Aetna Government |
$3.00
|
| Rate for Payer: Brighton Health Commercial |
$3.60
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$3.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$3.45
|
| Rate for Payer: Group Health Inc Commercial |
$3.00
|
| Rate for Payer: Group Health Inc Medicare |
$2.10
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$3.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$3.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3.90
|
|
|
FAMOTIDINE 20MG/50ML PRMX IVPB
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
41656075
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.00 |
| Max. Negotiated Rate |
$3.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$3.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$3.00
|
|
|
FAMOTIDINE 20MG/50ML PRMX IVPB
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
41646075
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.00 |
| Max. Negotiated Rate |
$3.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$3.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$3.00
|
|
|
FAMOTIDINE 20 MG PO TABS [10011]
|
Facility
|
OP
|
$0.09
|
|
|
Service Code
|
NDC 00904719361
|
| Hospital Charge Code |
00904719361
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.05
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.05
|
| Rate for Payer: Aetna Government |
$0.05
|
| Rate for Payer: Brighton Health Commercial |
$0.07
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.07
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.06
|
| Rate for Payer: Group Health Inc Commercial |
$0.05
|
| Rate for Payer: Group Health Inc Medicare |
$0.03
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.05
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.05
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.06
|
|
|
FAMOTIDINE 20 MG PO TABS [10011]
|
Facility
|
OP
|
$2.42
|
|
|
Service Code
|
NDC 00172572880
|
| Hospital Charge Code |
00172572880
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.85 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.33
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.21
|
| Rate for Payer: Aetna Government |
$1.21
|
| Rate for Payer: Brighton Health Commercial |
$1.82
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.94
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.65
|
| Rate for Payer: Group Health Inc Commercial |
$1.21
|
| Rate for Payer: Group Health Inc Medicare |
$0.85
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.21
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.21
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.57
|
|
|
FAMOTIDINE 20 MG PO TABS [10011]
|
Facility
|
OP
|
$1.52
|
|
|
Service Code
|
NDC 50268030315
|
| Hospital Charge Code |
50268030315
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.53 |
| Max. Negotiated Rate |
$1.21 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.83
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.76
|
| Rate for Payer: Aetna Government |
$0.76
|
| Rate for Payer: Brighton Health Commercial |
$1.14
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.21
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.03
|
| Rate for Payer: Group Health Inc Commercial |
$0.76
|
| Rate for Payer: Group Health Inc Medicare |
$0.53
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.76
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.76
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.99
|
|
