|
FL UROGRPHY NFS DRIP&/BOLUS
|
Facility
|
OP
|
$551.90
|
|
|
Service Code
|
HCPCS 74410 TC
|
| Hospital Charge Code |
41102144
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$148.73 |
| Max. Negotiated Rate |
$352.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$303.54
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$212.47
|
| Rate for Payer: Aetna Government |
$212.47
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$148.73
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$148.73
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$148.73
|
| Rate for Payer: Brighton Health Commercial |
$212.47
|
| Rate for Payer: Cash Price |
$212.47
|
| Rate for Payer: Cash Price |
$212.47
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$212.47
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$352.50
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$298.26
|
| Rate for Payer: Elderplan Medicare Advantage |
$212.47
|
| Rate for Payer: EmblemHealth Commercial |
$148.73
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$180.60
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$180.60
|
| Rate for Payer: Fidelis Essential Plan QHP |
$189.10
|
| Rate for Payer: Fidelis Medicare Advantage |
$212.47
|
| Rate for Payer: Fidelis Qualified Health Plan |
$189.10
|
| Rate for Payer: Group Health Inc Commercial |
$191.22
|
| Rate for Payer: Group Health Inc Medicare |
$191.22
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$275.95
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$212.47
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$191.22
|
| Rate for Payer: Healthfirst Medicare Advantage |
$212.47
|
| Rate for Payer: Healthfirst QHP |
$212.47
|
| Rate for Payer: Humana Medicare |
$216.72
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$212.47
|
| Rate for Payer: United Healthcare Medicare Advantage |
$212.47
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$212.47
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$169.98
|
| Rate for Payer: Wellcare Medicare |
$201.85
|
|
|
FL UROGRPHY NFS DRIP&/BOLUS
|
Facility
|
IP
|
$551.90
|
|
|
Service Code
|
HCPCS 74410 TC
|
| Hospital Charge Code |
41102144
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$212.47
|
|
|
FLUTAMIDE 125 MG CAP- NF
|
Facility
|
OP
|
$2.00
|
|
| Hospital Charge Code |
41640825
|
|
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
|
|
|
FLUTAMIDE 125 MG CAP- NF
|
Facility
|
OP
|
$2.00
|
|
| Hospital Charge Code |
41650825
|
|
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
|
|
|
FLUTAMIDE 125 MG PO CAPS [10081]
|
Facility
|
OP
|
$35.94
|
|
|
Service Code
|
NDC 80725060018
|
| Hospital Charge Code |
80725060018
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.58 |
| Max. Negotiated Rate |
$28.75 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$19.77
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$17.97
|
| Rate for Payer: Aetna Government |
$17.97
|
| Rate for Payer: Brighton Health Commercial |
$26.96
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$28.75
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$24.44
|
| Rate for Payer: Group Health Inc Commercial |
$17.97
|
| Rate for Payer: Group Health Inc Medicare |
$12.58
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$17.97
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$17.97
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$23.36
|
|
|
FLUTED STEM 15MMX100MM
|
Facility
|
OP
|
$3,068.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
40200740
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$134.20 |
| Max. Negotiated Rate |
$3,221.40 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,687.40
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$134.20
|
| Rate for Payer: Aetna Government |
$134.20
|
| Rate for Payer: Brighton Health Commercial |
$1,840.80
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,534.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,764.10
|
| Rate for Payer: EmblemHealth Commercial |
$1,534.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$3,221.40
|
| Rate for Payer: Group Health Inc Commercial |
$1,534.00
|
| Rate for Payer: Group Health Inc Medicare |
$1,073.80
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,534.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,534.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,994.20
|
|
|
FLUTED STEM 15MMX100MM
|
Facility
|
IP
|
$3,068.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
40200740
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,534.00 |
| Max. Negotiated Rate |
$1,534.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,534.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,534.00
|
|
|
FLUTED STEM 16MMX100MM
|
Facility
|
OP
|
$3,068.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
40200510
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$134.20 |
| Max. Negotiated Rate |
$3,221.40 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,687.40
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$134.20
|
| Rate for Payer: Aetna Government |
$134.20
|
| Rate for Payer: Brighton Health Commercial |
$1,840.80
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,534.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,764.10
|
| Rate for Payer: EmblemHealth Commercial |
$1,534.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$3,221.40
|
| Rate for Payer: Group Health Inc Commercial |
$1,534.00
|
| Rate for Payer: Group Health Inc Medicare |
$1,073.80
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,534.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,534.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,994.20
|
|
|
FLUTED STEM 16MMX100MM
|
Facility
|
IP
|
$3,068.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
40200510
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,534.00 |
| Max. Negotiated Rate |
$1,534.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,534.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,534.00
|
|
|
FLUTICASONE PROPIONATE 0.05% SPRAY
|
Facility
|
OP
|
$35.52
|
|
| Hospital Charge Code |
41652568
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.43 |
| Max. Negotiated Rate |
$28.42 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$19.54
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$17.76
|
| Rate for Payer: Aetna Government |
$17.76
|
| Rate for Payer: Brighton Health Commercial |
$26.64
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$28.42
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$24.15
|
| Rate for Payer: Group Health Inc Commercial |
$17.76
|
| Rate for Payer: Group Health Inc Medicare |
$12.43
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$17.76
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$17.76
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$23.09
|
|
|
FLUTICASONE PROPIONATE 0.05% SPRAY
|
Facility
|
OP
|
$35.52
|
|
| Hospital Charge Code |
41642568
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.43 |
| Max. Negotiated Rate |
$28.42 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$19.54
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$17.76
|
| Rate for Payer: Aetna Government |
$17.76
|
| Rate for Payer: Brighton Health Commercial |
$26.64
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$28.42
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$24.15
|
| Rate for Payer: Group Health Inc Commercial |
$17.76
|
| Rate for Payer: Group Health Inc Medicare |
$12.43
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$17.76
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$17.76
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$23.09
|
|
|
FLUTICASONE PROPIONATE 50 MCG/ACT NA SUSP [70536]
|
Facility
|
OP
|
$5.27
|
|
|
Service Code
|
NDC 50383070016
|
| Hospital Charge Code |
50383070016
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.84 |
| Max. Negotiated Rate |
$4.22 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2.90
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.64
|
| Rate for Payer: Aetna Government |
$2.64
|
| Rate for Payer: Brighton Health Commercial |
$3.95
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$4.22
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$3.58
|
| Rate for Payer: Group Health Inc Commercial |
$2.64
|
| Rate for Payer: Group Health Inc Medicare |
$1.84
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.64
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2.64
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3.43
|
|
|
FLUTICASONE PROPIONATE 50 MCG/ACT NA SUSP [70536]
|
Facility
|
OP
|
$5.83
|
|
|
Service Code
|
NDC 00054327099
|
| Hospital Charge Code |
00054327099
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.04 |
| Max. Negotiated Rate |
$4.67 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$3.21
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.92
|
| Rate for Payer: Aetna Government |
$2.92
|
| Rate for Payer: Brighton Health Commercial |
$4.37
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$4.67
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$3.97
|
| Rate for Payer: Group Health Inc Commercial |
$2.92
|
| Rate for Payer: Group Health Inc Medicare |
$2.04
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.92
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2.92
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3.79
|
|
|
FLUTICASONE PROPIONATE 50 MCG/ACT NA SUSP [70536]
|
Facility
|
OP
|
$5.33
|
|
|
Service Code
|
NDC 60432026415
|
| Hospital Charge Code |
60432026415
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.87 |
| Max. Negotiated Rate |
$4.26 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2.93
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.66
|
| Rate for Payer: Aetna Government |
$2.66
|
| Rate for Payer: Brighton Health Commercial |
$4.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$4.26
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$3.62
|
| Rate for Payer: Group Health Inc Commercial |
$2.66
|
| Rate for Payer: Group Health Inc Medicare |
$1.87
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.66
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2.66
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3.46
|
|
|
FLUTICASONE PROPIONATE 50 MCG/ACT NA SUSP [70536]
|
Facility
|
OP
|
$1.22
|
|
|
Service Code
|
NDC 70000011001
|
| Hospital Charge Code |
70000011001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$0.98 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.67
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.61
|
| Rate for Payer: Aetna Government |
$0.61
|
| Rate for Payer: Brighton Health Commercial |
$0.92
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.98
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.83
|
| Rate for Payer: Group Health Inc Commercial |
$0.61
|
| Rate for Payer: Group Health Inc Medicare |
$0.43
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.61
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.61
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.79
|
|
|
FLUTICASONE PROPIONATE 50 MCG/ACT NA SUSP [70536]
|
Facility
|
OP
|
$5.33
|
|
|
Service Code
|
NDC 60505082901
|
| Hospital Charge Code |
60505082901
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.87 |
| Max. Negotiated Rate |
$4.26 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2.93
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.66
|
| Rate for Payer: Aetna Government |
$2.66
|
| Rate for Payer: Brighton Health Commercial |
$4.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$4.26
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$3.62
|
| Rate for Payer: Group Health Inc Commercial |
$2.66
|
| Rate for Payer: Group Health Inc Medicare |
$1.87
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.66
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2.66
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3.46
|
|
|
FLUTICASONE PROPIONATE 50 MCG/ACT NA SUSP [70536]
|
Facility
|
OP
|
$1.20
|
|
|
Service Code
|
NDC 00536118399
|
| Hospital Charge Code |
00536118399
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.42 |
| Max. Negotiated Rate |
$0.96 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.66
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.60
|
| Rate for Payer: Aetna Government |
$0.60
|
| Rate for Payer: Brighton Health Commercial |
$0.90
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.96
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.82
|
| Rate for Payer: Group Health Inc Commercial |
$0.60
|
| Rate for Payer: Group Health Inc Medicare |
$0.42
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.60
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.60
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.78
|
|
|
FLU VACCINE 6-35 MO IM
|
Facility
|
IP
|
$15.15
|
|
|
Service Code
|
HCPCS 90657
|
| Hospital Charge Code |
30301211
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.58 |
| Max. Negotiated Rate |
$7.58 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$7.58
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$7.58
|
|
|
FLU VACCINE 6-35 MO IM
|
Facility
|
OP
|
$15.15
|
|
|
Service Code
|
HCPCS 90657
|
| Hospital Charge Code |
30301211
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.30 |
| Max. Negotiated Rate |
$574.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$8.33
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$9.50
|
| Rate for Payer: Aetna Government |
$9.50
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$12.92
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$12.92
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$5.74
|
| Rate for Payer: Amida Care Medicaid |
$5.74
|
| Rate for Payer: Brighton Health Commercial |
$9.09
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$7.58
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$8.71
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$574.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$5.74
|
| Rate for Payer: Fidelis Essential Plan QHP |
$5.74
|
| Rate for Payer: Fidelis Qualified Health Plan |
$6.03
|
| Rate for Payer: Group Health Inc Commercial |
$7.58
|
| Rate for Payer: Group Health Inc Medicare |
$5.30
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$5.74
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$7.58
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$5.74
|
| Rate for Payer: Healthfirst Essential Plan |
$12.92
|
| Rate for Payer: Healthfirst QHP |
$5.74
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$5.74
|
| Rate for Payer: SOMOS Essential |
$5.74
|
| Rate for Payer: United Healthcare Commercial |
$13.22
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$12.92
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$6.31
|
| Rate for Payer: United Healthcare Medicaid |
$5.74
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$9.85
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$5.74
|
|
|
FLU VACCINE MM
|
Facility
|
OP
|
$24.90
|
|
|
Service Code
|
HCPCS 90658
|
| Hospital Charge Code |
30400268
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.72 |
| Max. Negotiated Rate |
$1,148.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$13.70
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$16.32
|
| Rate for Payer: Aetna Government |
$16.32
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$25.83
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$25.83
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$11.48
|
| Rate for Payer: Amida Care Medicaid |
$11.48
|
| Rate for Payer: Brighton Health Commercial |
$14.94
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$12.45
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$14.32
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$1,148.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$11.48
|
| Rate for Payer: Fidelis Essential Plan QHP |
$11.48
|
| Rate for Payer: Fidelis Qualified Health Plan |
$12.05
|
| Rate for Payer: Group Health Inc Commercial |
$12.45
|
| Rate for Payer: Group Health Inc Medicare |
$8.72
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$11.48
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$12.45
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$11.48
|
| Rate for Payer: Healthfirst Essential Plan |
$25.83
|
| Rate for Payer: Healthfirst QHP |
$11.48
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$11.48
|
| Rate for Payer: SOMOS Essential |
$11.48
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$25.83
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$12.63
|
| Rate for Payer: United Healthcare Medicaid |
$11.48
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$16.18
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$11.48
|
|
|
FLU VACCINE MM
|
Facility
|
IP
|
$24.90
|
|
|
Service Code
|
HCPCS 90658
|
| Hospital Charge Code |
30400268
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.45 |
| Max. Negotiated Rate |
$12.45 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$12.45
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$12.45
|
|
|
FLU VACCINE SPLIT VIRUS
|
Facility
|
OP
|
$33.05
|
|
| Hospital Charge Code |
40501002
|
|
Hospital Revenue Code
|
940
|
| Min. Negotiated Rate |
$11.57 |
| Max. Negotiated Rate |
$26.44 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$18.18
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$16.52
|
| Rate for Payer: Aetna Government |
$16.52
|
| Rate for Payer: Brighton Health Commercial |
$24.79
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$26.44
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$22.47
|
| Rate for Payer: Group Health Inc Commercial |
$16.52
|
| Rate for Payer: Group Health Inc Medicare |
$11.57
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$16.52
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$16.52
|
| Rate for Payer: United Healthcare Commercial |
$16.52
|
|
|
FLU VACCINE WHOLE
|
Facility
|
OP
|
$24.90
|
|
|
Service Code
|
HCPCS 90658
|
| Hospital Charge Code |
30300182
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.72 |
| Max. Negotiated Rate |
$1,148.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$13.70
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$16.32
|
| Rate for Payer: Aetna Government |
$16.32
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$25.83
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$25.83
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$11.48
|
| Rate for Payer: Amida Care Medicaid |
$11.48
|
| Rate for Payer: Brighton Health Commercial |
$14.94
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$12.45
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$14.32
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$1,148.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$11.48
|
| Rate for Payer: Fidelis Essential Plan QHP |
$11.48
|
| Rate for Payer: Fidelis Qualified Health Plan |
$12.05
|
| Rate for Payer: Group Health Inc Commercial |
$12.45
|
| Rate for Payer: Group Health Inc Medicare |
$8.72
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$11.48
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$12.45
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$11.48
|
| Rate for Payer: Healthfirst Essential Plan |
$25.83
|
| Rate for Payer: Healthfirst QHP |
$11.48
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$11.48
|
| Rate for Payer: SOMOS Essential |
$11.48
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$25.83
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$12.63
|
| Rate for Payer: United Healthcare Medicaid |
$11.48
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$16.18
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$11.48
|
|
|
FLU VACCINE WHOLE
|
Facility
|
IP
|
$24.90
|
|
|
Service Code
|
HCPCS 90658
|
| Hospital Charge Code |
30300182
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.45 |
| Max. Negotiated Rate |
$12.45 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$12.45
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$12.45
|
|
|
FLU VAC,SPLIT VIRUS,PRESERV FREE
|
Facility
|
OP
|
$45.80
|
|
| Hospital Charge Code |
40501001
|
|
Hospital Revenue Code
|
940
|
| Min. Negotiated Rate |
$16.03 |
| Max. Negotiated Rate |
$36.64 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$25.19
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$22.90
|
| Rate for Payer: Aetna Government |
$22.90
|
| Rate for Payer: Brighton Health Commercial |
$34.35
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$36.64
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$31.14
|
| Rate for Payer: Group Health Inc Commercial |
$22.90
|
| Rate for Payer: Group Health Inc Medicare |
$16.03
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$22.90
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$22.90
|
| Rate for Payer: United Healthcare Commercial |
$22.90
|
|
