|
AMALGAM-TWO SURFACES, PERMANENT
|
Facility
|
IP
|
$167.50
|
|
|
Service Code
|
HCPCS D2150
|
| Hospital Charge Code |
42300350
|
|
Hospital Revenue Code
|
361
|
| Rate for Payer: Cash Price |
$1,018.19
|
|
|
AMALGAM-TWO SURFACES, PERMANENT
|
Facility
|
OP
|
$167.50
|
|
|
Service Code
|
HCPCS D2150
|
| Hospital Charge Code |
42300350
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$83.75 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$92.12
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,018.19
|
| Rate for Payer: Aetna Government |
$1,018.19
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$712.73
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$712.73
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$712.73
|
| Rate for Payer: Brighton Health Commercial |
$125.62
|
| Rate for Payer: Cash Price |
$1,018.19
|
| Rate for Payer: Cash Price |
$1,018.19
|
| Rate for Payer: Cash Price |
$1,018.19
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,018.19
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2,915.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,477.75
|
| Rate for Payer: Elderplan Medicare Advantage |
$1,018.19
|
| Rate for Payer: EmblemHealth Commercial |
$1,018.19
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$865.46
|
| Rate for Payer: Fidelis Essential Plan QHP |
$906.19
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,018.19
|
| Rate for Payer: Fidelis Qualified Health Plan |
$906.19
|
| Rate for Payer: Group Health Inc Commercial |
$1,018.19
|
| Rate for Payer: Group Health Inc Medicare |
$1,018.19
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$83.75
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,018.19
|
| Rate for Payer: Healthfirst Medicare Advantage |
$865.46
|
| Rate for Payer: Healthfirst QHP |
$1,018.19
|
| Rate for Payer: Humana Medicare |
$1,038.55
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,018.19
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,018.19
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,018.19
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$814.55
|
| Rate for Payer: Wellcare Medicare |
$967.28
|
|
|
AMANTADINE 100 MG CAP
|
Facility
|
OP
|
$2.00
|
|
| Hospital Charge Code |
41640859
|
|
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: Brighton Health Commercial |
$1.50
|
| 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
|
|
|
AMANTADINE 100 MG CAP
|
Facility
|
OP
|
$2.00
|
|
| Hospital Charge Code |
41650859
|
|
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: Brighton Health Commercial |
$1.50
|
| 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
|
|
|
AMANTADINE 100MG TAB
|
Facility
|
OP
|
$2.74
|
|
| Hospital Charge Code |
41547912
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.96 |
| Max. Negotiated Rate |
$2.19 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.51
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.37
|
| Rate for Payer: Aetna Government |
$1.37
|
| Rate for Payer: Brighton Health Commercial |
$2.06
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2.19
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.86
|
| 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: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.78
|
|
|
AMANTADINE 100MG TAB
|
Facility
|
OP
|
$2.74
|
|
| Hospital Charge Code |
41657912
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.96 |
| Max. Negotiated Rate |
$2.19 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.51
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.37
|
| Rate for Payer: Aetna Government |
$1.37
|
| Rate for Payer: Brighton Health Commercial |
$2.06
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2.19
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.86
|
| 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: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.78
|
|
|
AMANTADINE 100MG TAB
|
Facility
|
OP
|
$2.74
|
|
| Hospital Charge Code |
41647912
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.96 |
| Max. Negotiated Rate |
$2.19 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.51
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.37
|
| Rate for Payer: Aetna Government |
$1.37
|
| Rate for Payer: Brighton Health Commercial |
$2.06
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2.19
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.86
|
| 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: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.78
|
|
|
AMANTADINE 10 MG/ML SYRUP
|
Facility
|
OP
|
$13.00
|
|
| Hospital Charge Code |
41653129
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.55 |
| Max. Negotiated Rate |
$10.40 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$7.15
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$6.50
|
| Rate for Payer: Aetna Government |
$6.50
|
| Rate for Payer: Brighton Health Commercial |
$9.75
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$10.40
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$8.84
|
| Rate for Payer: Group Health Inc Commercial |
$6.50
|
| Rate for Payer: Group Health Inc Medicare |
$4.55
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$6.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$6.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$8.45
|
|
|
AMANTADINE 10 MG/ML SYRUP
|
Facility
|
OP
|
$13.00
|
|
| Hospital Charge Code |
41643129
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.55 |
| Max. Negotiated Rate |
$10.40 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$7.15
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$6.50
|
| Rate for Payer: Aetna Government |
$6.50
|
| Rate for Payer: Brighton Health Commercial |
$9.75
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$10.40
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$8.84
|
| Rate for Payer: Group Health Inc Commercial |
$6.50
|
| Rate for Payer: Group Health Inc Medicare |
$4.55
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$6.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$6.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$8.45
|
|
|
AMANTADINE HCL 100 MG PO CAPS [364]
|
Facility
|
OP
|
$2.02
|
|
|
Service Code
|
NDC 00832101550
|
| Hospital Charge Code |
00832101550
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.71 |
| Max. Negotiated Rate |
$1.62 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.11
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.01
|
| Rate for Payer: Aetna Government |
$1.01
|
| Rate for Payer: Brighton Health Commercial |
$1.51
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.62
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.37
|
| Rate for Payer: Group Health Inc Commercial |
$1.01
|
| Rate for Payer: Group Health Inc Medicare |
$0.71
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.01
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.01
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.31
|
|
|
AMANTADINE HCL 100 MG PO TABS [20506]
|
Facility
|
OP
|
$2.28
|
|
|
Service Code
|
NDC 42543049701
|
| Hospital Charge Code |
42543049701
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.80 |
| Max. Negotiated Rate |
$1.83 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.26
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.14
|
| Rate for Payer: Aetna Government |
$1.14
|
| Rate for Payer: Brighton Health Commercial |
$1.71
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.83
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.55
|
| Rate for Payer: Group Health Inc Commercial |
$1.14
|
| Rate for Payer: Group Health Inc Medicare |
$0.80
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.14
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.14
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.48
|
|
|
AMANTADINE HCL 100 MG PO TABS [20506]
|
Facility
|
OP
|
$2.74
|
|
|
Service Code
|
NDC 00832011103
|
| Hospital Charge Code |
00832011103
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.96 |
| Max. Negotiated Rate |
$2.20 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.51
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.37
|
| Rate for Payer: Aetna Government |
$1.37
|
| Rate for Payer: Brighton Health Commercial |
$2.06
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2.20
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.87
|
| 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: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.78
|
|
|
AMANTADINE HCL 50 MG/5ML PO SOLN [180668]
|
Facility
|
OP
|
$0.43
|
|
|
Service Code
|
NDC 00121064610
|
| Hospital Charge Code |
00121064610
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.34 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.24
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.22
|
| Rate for Payer: Aetna Government |
$0.22
|
| Rate for Payer: Brighton Health Commercial |
$0.32
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.34
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.29
|
| Rate for Payer: Group Health Inc Commercial |
$0.22
|
| Rate for Payer: Group Health Inc Medicare |
$0.15
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.22
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.22
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.28
|
|
|
AMB CONT GLUCOSE MONT & REPORT
|
Facility
|
OP
|
$113.69
|
|
|
Service Code
|
HCPCS 95251
|
| Hospital Charge Code |
30305450
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$37.22 |
| Max. Negotiated Rate |
$250.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$62.53
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$37.22
|
| Rate for Payer: Aetna Government |
$37.22
|
| Rate for Payer: Brighton Health Commercial |
$233.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$204.58
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$173.89
|
| Rate for Payer: Group Health Inc Commercial |
$250.00
|
| Rate for Payer: Group Health Inc Medicare |
$250.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$56.84
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$56.84
|
| Rate for Payer: United Healthcare Commercial |
$222.00
|
|
|
AMB CONTINUOUS GLUCOSE MONITORING
|
Facility
|
IP
|
$351.13
|
|
|
Service Code
|
HCPCS 95250
|
| Hospital Charge Code |
30305904
|
|
Hospital Revenue Code
|
920
|
| Rate for Payer: Cash Price |
$152.87
|
|
|
AMB CONTINUOUS GLUCOSE MONITORING
|
Facility
|
OP
|
$351.13
|
|
|
Service Code
|
HCPCS 95250
|
| Hospital Charge Code |
30305904
|
|
Hospital Revenue Code
|
920
|
| Min. Negotiated Rate |
$94.00 |
| Max. Negotiated Rate |
$280.90 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$193.12
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$152.87
|
| Rate for Payer: Aetna Government |
$152.87
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$107.01
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$107.01
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$107.01
|
| Rate for Payer: Brighton Health Commercial |
$263.35
|
| Rate for Payer: Cash Price |
$152.87
|
| Rate for Payer: Cash Price |
$152.87
|
| Rate for Payer: Cash Price |
$152.87
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$152.87
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$280.90
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$238.77
|
| Rate for Payer: Elderplan Medicare Advantage |
$152.87
|
| Rate for Payer: EmblemHealth Commercial |
$152.87
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$129.94
|
| Rate for Payer: Fidelis Essential Plan QHP |
$136.05
|
| Rate for Payer: Fidelis Medicare Advantage |
$152.87
|
| Rate for Payer: Fidelis Qualified Health Plan |
$136.05
|
| Rate for Payer: Group Health Inc Commercial |
$152.87
|
| Rate for Payer: Group Health Inc Medicare |
$152.87
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$175.56
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$152.87
|
| Rate for Payer: Healthfirst Medicare Advantage |
$129.94
|
| Rate for Payer: Healthfirst QHP |
$152.87
|
| Rate for Payer: Humana Medicare |
$155.93
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$152.87
|
| Rate for Payer: United Healthcare Commercial |
$94.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$152.87
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$152.87
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$122.30
|
| Rate for Payer: Wellcare Medicare |
$145.23
|
|
|
AMEANEX 110MCG
|
Facility
|
OP
|
$49.00
|
|
| Hospital Charge Code |
41648140
|
|
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
|
|
|
AMEBIASIS ANTIBODIES
|
Facility
|
IP
|
$30.98
|
|
|
Service Code
|
HCPCS 86753
|
| Hospital Charge Code |
40619179
|
|
Hospital Revenue Code
|
300
|
| Rate for Payer: Cash Price |
$12.39
|
|
|
AMEBIASIS ANTIBODIES
|
Facility
|
OP
|
$30.98
|
|
|
Service Code
|
HCPCS 86753
|
| Hospital Charge Code |
40619179
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.67 |
| Max. Negotiated Rate |
$23.24 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$17.04
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$12.39
|
| Rate for Payer: Aetna Government |
$12.39
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$8.67
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$8.67
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$8.67
|
| Rate for Payer: Brighton Health Commercial |
$23.24
|
| Rate for Payer: Cash Price |
$12.39
|
| Rate for Payer: Cash Price |
$12.39
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$12.39
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$19.70
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$16.66
|
| Rate for Payer: Elderplan Medicare Advantage |
$12.39
|
| Rate for Payer: EmblemHealth Commercial |
$12.39
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$10.53
|
| Rate for Payer: Fidelis Essential Plan QHP |
$11.03
|
| Rate for Payer: Fidelis Medicare Advantage |
$12.39
|
| Rate for Payer: Fidelis Qualified Health Plan |
$11.03
|
| Rate for Payer: Group Health Inc Commercial |
$12.39
|
| Rate for Payer: Group Health Inc Medicare |
$12.39
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$15.49
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$12.39
|
| Rate for Payer: Healthfirst Medicare Advantage |
$12.39
|
| Rate for Payer: Healthfirst QHP |
$12.39
|
| Rate for Payer: Humana Medicare |
$12.64
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$12.39
|
| Rate for Payer: United Healthcare Commercial |
$15.69
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.39
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$12.39
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$9.91
|
| Rate for Payer: Wellcare Medicare |
$11.15
|
|
|
AMIFOSTINE 500 MG INJ
|
Facility
|
OP
|
$607.35
|
|
|
Service Code
|
HCPCS J0207
|
| Hospital Charge Code |
41644988
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$212.57 |
| Max. Negotiated Rate |
$887.13 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$334.04
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$887.13
|
| Rate for Payer: Aetna Government |
$887.13
|
| Rate for Payer: Brighton Health Commercial |
$364.41
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$303.68
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$349.23
|
| Rate for Payer: Group Health Inc Commercial |
$303.68
|
| Rate for Payer: Group Health Inc Medicare |
$212.57
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$303.68
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$303.68
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$394.78
|
|
|
AMIFOSTINE 500 MG INJ
|
Facility
|
IP
|
$607.35
|
|
|
Service Code
|
HCPCS J0207
|
| Hospital Charge Code |
41644988
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$303.68 |
| Max. Negotiated Rate |
$303.68 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$303.68
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$303.68
|
|
|
AMIFOSTINE 500 MG INJ
|
Facility
|
OP
|
$607.35
|
|
|
Service Code
|
HCPCS J0207
|
| Hospital Charge Code |
41654988
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$212.57 |
| Max. Negotiated Rate |
$887.13 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$334.04
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$887.13
|
| Rate for Payer: Aetna Government |
$887.13
|
| Rate for Payer: Brighton Health Commercial |
$364.41
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$303.68
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$349.23
|
| Rate for Payer: Group Health Inc Commercial |
$303.68
|
| Rate for Payer: Group Health Inc Medicare |
$212.57
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$303.68
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$303.68
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$394.78
|
|
|
AMIFOSTINE 500 MG INJ
|
Facility
|
IP
|
$607.35
|
|
|
Service Code
|
HCPCS J0207
|
| Hospital Charge Code |
41654988
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$303.68 |
| Max. Negotiated Rate |
$303.68 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$303.68
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$303.68
|
|
|
AMIKACIN
|
Facility
|
OP
|
$37.70
|
|
|
Service Code
|
HCPCS 80150
|
| Hospital Charge Code |
40602010
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$10.56 |
| Max. Negotiated Rate |
$28.28 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$20.74
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$15.08
|
| Rate for Payer: Aetna Government |
$15.08
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$10.56
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$10.56
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$10.56
|
| Rate for Payer: Brighton Health Commercial |
$28.28
|
| Rate for Payer: Cash Price |
$15.08
|
| Rate for Payer: Cash Price |
$15.08
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$15.08
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$23.97
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$20.28
|
| Rate for Payer: Elderplan Medicare Advantage |
$15.08
|
| Rate for Payer: EmblemHealth Commercial |
$15.08
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$12.82
|
| Rate for Payer: Fidelis Essential Plan QHP |
$13.42
|
| Rate for Payer: Fidelis Medicare Advantage |
$15.08
|
| Rate for Payer: Fidelis Qualified Health Plan |
$13.42
|
| Rate for Payer: Group Health Inc Commercial |
$15.08
|
| Rate for Payer: Group Health Inc Medicare |
$15.08
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$18.85
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$15.08
|
| Rate for Payer: Healthfirst Medicare Advantage |
$15.08
|
| Rate for Payer: Healthfirst QHP |
$15.08
|
| Rate for Payer: Humana Medicare |
$15.38
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$15.08
|
| Rate for Payer: United Healthcare Commercial |
$19.09
|
| Rate for Payer: United Healthcare Medicare Advantage |
$15.08
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$15.08
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$12.06
|
| Rate for Payer: Wellcare Medicare |
$13.57
|
|
|
AMIKACIN
|
Facility
|
IP
|
$37.70
|
|
|
Service Code
|
HCPCS 80150
|
| Hospital Charge Code |
40602010
|
|
Hospital Revenue Code
|
301
|
| Rate for Payer: Cash Price |
$15.08
|
|
