|
FOLEY CATHETER TRAY
|
Facility
|
OP
|
$28.35
|
|
| Hospital Charge Code |
40201830
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$9.92 |
| Max. Negotiated Rate |
$22.68 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$15.59
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$14.18
|
| Rate for Payer: Aetna Government |
$14.18
|
| Rate for Payer: Brighton Health Commercial |
$21.26
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$22.68
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$19.28
|
| Rate for Payer: Group Health Inc Commercial |
$14.18
|
| Rate for Payer: Group Health Inc Medicare |
$9.92
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$14.18
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$14.18
|
|
|
FOLEY TROCAR
|
Facility
|
OP
|
$194.48
|
|
| Hospital Charge Code |
64907180
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$68.07 |
| Max. Negotiated Rate |
$155.58 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$106.96
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$97.24
|
| Rate for Payer: Aetna Government |
$97.24
|
| Rate for Payer: Brighton Health Commercial |
$145.86
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$155.58
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$132.25
|
| Rate for Payer: Group Health Inc Commercial |
$97.24
|
| Rate for Payer: Group Health Inc Medicare |
$68.07
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$97.24
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$97.24
|
|
|
FOLIC ACID 0.5 MG/ML SOLN
|
Facility
|
OP
|
$1.00
|
|
| Hospital Charge Code |
41652136
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$0.80 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.55
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.50
|
| Rate for Payer: Aetna Government |
$0.50
|
| Rate for Payer: Brighton Health Commercial |
$0.75
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.80
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.68
|
| Rate for Payer: Group Health Inc Commercial |
$0.50
|
| Rate for Payer: Group Health Inc Medicare |
$0.35
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.65
|
|
|
FOLIC ACID 0.5 MG/ML SOLN
|
Facility
|
OP
|
$1.00
|
|
| Hospital Charge Code |
41642136
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$0.80 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.55
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.50
|
| Rate for Payer: Aetna Government |
$0.50
|
| Rate for Payer: Brighton Health Commercial |
$0.75
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.80
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.68
|
| Rate for Payer: Group Health Inc Commercial |
$0.50
|
| Rate for Payer: Group Health Inc Medicare |
$0.35
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.65
|
|
|
FOLIC ACID 1 MG PO TABS [3233]
|
Facility
|
OP
|
$0.19
|
|
|
Service Code
|
NDC 62584089701
|
| Hospital Charge Code |
62584089701
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.10
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.10
|
| Rate for Payer: Aetna Government |
$0.10
|
| Rate for Payer: Brighton Health Commercial |
$0.14
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.15
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.13
|
| Rate for Payer: Group Health Inc Commercial |
$0.10
|
| Rate for Payer: Group Health Inc Medicare |
$0.07
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.10
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.10
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.12
|
|
|
FOLIC ACID 1 MG PO TABS [3233]
|
Facility
|
OP
|
$0.20
|
|
|
Service Code
|
NDC 00904722461
|
| Hospital Charge Code |
00904722461
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.11
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.10
|
| Rate for Payer: Aetna Government |
$0.10
|
| Rate for Payer: Brighton Health Commercial |
$0.15
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.16
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.14
|
| Rate for Payer: Group Health Inc Commercial |
$0.10
|
| Rate for Payer: Group Health Inc Medicare |
$0.07
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.10
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.10
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.13
|
|
|
FOLIC ACID 1 MG PO TABS [3233]
|
Facility
|
OP
|
$0.08
|
|
|
Service Code
|
NDC 53746036110
|
| Hospital Charge Code |
53746036110
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.04
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.04
|
| Rate for Payer: Aetna Government |
$0.04
|
| Rate for Payer: Brighton Health Commercial |
$0.06
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.06
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.05
|
| Rate for Payer: Group Health Inc Commercial |
$0.04
|
| Rate for Payer: Group Health Inc Medicare |
$0.03
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.04
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.04
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.05
|
|
|
FOLIC ACID 1 MG PO TABS [3233]
|
Facility
|
OP
|
$0.02
|
|
|
Service Code
|
NDC 54629012800
|
| Hospital Charge Code |
54629012800
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.01 |
| 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 |
$0.01
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.01
|
| Rate for Payer: Group Health Inc Commercial |
$0.01
|
| Rate for Payer: Group Health Inc Medicare |
$0.01
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.01
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.01
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.01
|
|
|
FOLIC ACID 1 MG PO TABS [3233]
|
Facility
|
OP
|
$0.08
|
|
|
Service Code
|
NDC 69315012710
|
| Hospital Charge Code |
69315012710
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.04
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.04
|
| Rate for Payer: Aetna Government |
$0.04
|
| Rate for Payer: Brighton Health Commercial |
$0.06
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.06
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.05
|
| Rate for Payer: Group Health Inc Commercial |
$0.04
|
| Rate for Payer: Group Health Inc Medicare |
$0.03
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.04
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.04
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.05
|
|
|
FOLIC ACID 1 MG PO TABS [3233]
|
Facility
|
OP
|
$0.21
|
|
|
Service Code
|
NDC 60687068101
|
| Hospital Charge Code |
60687068101
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.11
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.10
|
| Rate for Payer: Aetna Government |
$0.10
|
| Rate for Payer: Brighton Health Commercial |
$0.16
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.17
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.14
|
| Rate for Payer: Group Health Inc Commercial |
$0.10
|
| Rate for Payer: Group Health Inc Medicare |
$0.07
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.10
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.10
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.14
|
|
|
FOLIC ACID 1 MG PO TABS [3233]
|
Facility
|
OP
|
$0.08
|
|
|
Service Code
|
NDC 11534016503
|
| Hospital Charge Code |
11534016503
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.04
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.04
|
| Rate for Payer: Aetna Government |
$0.04
|
| Rate for Payer: Brighton Health Commercial |
$0.06
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.06
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.05
|
| Rate for Payer: Group Health Inc Commercial |
$0.04
|
| Rate for Payer: Group Health Inc Medicare |
$0.03
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.04
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.04
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.05
|
|
|
FOLIC ACID 1 MG PO TABS [3233]
|
Facility
|
OP
|
$0.08
|
|
|
Service Code
|
NDC 58657015110
|
| Hospital Charge Code |
58657015110
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.04
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.04
|
| Rate for Payer: Aetna Government |
$0.04
|
| Rate for Payer: Brighton Health Commercial |
$0.06
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.06
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.05
|
| Rate for Payer: Group Health Inc Commercial |
$0.04
|
| Rate for Payer: Group Health Inc Medicare |
$0.03
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.04
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.04
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.05
|
|
|
FOLIC ACID 1 MG TAB
|
Facility
|
OP
|
$1.00
|
|
| Hospital Charge Code |
41640257
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$0.80 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.55
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.50
|
| Rate for Payer: Aetna Government |
$0.50
|
| Rate for Payer: Brighton Health Commercial |
$0.75
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.80
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.68
|
| Rate for Payer: Group Health Inc Commercial |
$0.50
|
| Rate for Payer: Group Health Inc Medicare |
$0.35
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.65
|
|
|
FOLIC ACID 1 MG TAB
|
Facility
|
OP
|
$1.00
|
|
| Hospital Charge Code |
41650257
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$0.80 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.55
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.50
|
| Rate for Payer: Aetna Government |
$0.50
|
| Rate for Payer: Brighton Health Commercial |
$0.75
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.80
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.68
|
| Rate for Payer: Group Health Inc Commercial |
$0.50
|
| Rate for Payer: Group Health Inc Medicare |
$0.35
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.65
|
|
|
FOLIC ACID 5 MG/ML IJ SOLN [3232]
|
Facility
|
OP
|
$4.38
|
|
|
Service Code
|
NDC 39822110001
|
| Hospital Charge Code |
39822110001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.53 |
| Max. Negotiated Rate |
$3.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2.41
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.19
|
| Rate for Payer: Aetna Government |
$2.19
|
| Rate for Payer: Brighton Health Commercial |
$3.28
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$3.50
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2.98
|
| Rate for Payer: Group Health Inc Commercial |
$2.19
|
| Rate for Payer: Group Health Inc Medicare |
$1.53
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.19
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2.19
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2.84
|
|
|
FOLIC ACID 5 MG/ML IJ SOLN [3232]
|
Facility
|
OP
|
$5.90
|
|
|
Service Code
|
NDC 63323018410
|
| Hospital Charge Code |
63323018410
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.07 |
| Max. Negotiated Rate |
$4.72 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$3.25
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.95
|
| Rate for Payer: Aetna Government |
$2.95
|
| Rate for Payer: Brighton Health Commercial |
$4.43
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$4.72
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$4.01
|
| Rate for Payer: Group Health Inc Commercial |
$2.95
|
| Rate for Payer: Group Health Inc Medicare |
$2.07
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.95
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2.95
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3.84
|
|
|
FOLIC ACID 5 MG/ML INJ MDV
|
Facility
|
OP
|
$37.38
|
|
| Hospital Charge Code |
41643503
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.08 |
| Max. Negotiated Rate |
$29.90 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$20.56
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$18.69
|
| Rate for Payer: Aetna Government |
$18.69
|
| Rate for Payer: Brighton Health Commercial |
$28.04
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$29.90
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$25.42
|
| Rate for Payer: Group Health Inc Commercial |
$18.69
|
| Rate for Payer: Group Health Inc Medicare |
$13.08
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$18.69
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$18.69
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$24.30
|
|
|
FOLIC ACID 5 MG/ML INJ MDV
|
Facility
|
OP
|
$37.38
|
|
| Hospital Charge Code |
41653503
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.08 |
| Max. Negotiated Rate |
$29.90 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$20.56
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$18.69
|
| Rate for Payer: Aetna Government |
$18.69
|
| Rate for Payer: Brighton Health Commercial |
$28.04
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$29.90
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$25.42
|
| Rate for Payer: Group Health Inc Commercial |
$18.69
|
| Rate for Payer: Group Health Inc Medicare |
$13.08
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$18.69
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$18.69
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$24.30
|
|
|
FOLIC ACID RIA
|
Facility
|
IP
|
$36.75
|
|
|
Service Code
|
HCPCS 82746
|
| Hospital Charge Code |
40602370
|
|
Hospital Revenue Code
|
301
|
| Rate for Payer: Cash Price |
$14.70
|
|
|
FOLIC ACID RIA
|
Facility
|
OP
|
$36.75
|
|
|
Service Code
|
HCPCS 82746
|
| Hospital Charge Code |
40602370
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$10.29 |
| Max. Negotiated Rate |
$27.56 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$20.21
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$14.70
|
| Rate for Payer: Aetna Government |
$14.70
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$10.29
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$10.29
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$10.29
|
| Rate for Payer: Brighton Health Commercial |
$27.56
|
| Rate for Payer: Cash Price |
$14.70
|
| Rate for Payer: Cash Price |
$14.70
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$14.70
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$23.37
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$19.78
|
| Rate for Payer: Elderplan Medicare Advantage |
$14.70
|
| Rate for Payer: EmblemHealth Commercial |
$14.70
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$12.50
|
| Rate for Payer: Fidelis Essential Plan QHP |
$13.08
|
| Rate for Payer: Fidelis Medicare Advantage |
$14.70
|
| Rate for Payer: Fidelis Qualified Health Plan |
$13.08
|
| Rate for Payer: Group Health Inc Commercial |
$14.70
|
| Rate for Payer: Group Health Inc Medicare |
$14.70
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$18.38
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$14.70
|
| Rate for Payer: Healthfirst Medicare Advantage |
$14.70
|
| Rate for Payer: Healthfirst QHP |
$14.70
|
| Rate for Payer: Humana Medicare |
$14.99
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$14.70
|
| Rate for Payer: United Healthcare Commercial |
$18.62
|
| Rate for Payer: United Healthcare Medicare Advantage |
$14.70
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$14.70
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$11.76
|
| Rate for Payer: Wellcare Medicare |
$13.23
|
|
|
FOLLOW UP
|
Facility
|
OP
|
$503.49
|
|
|
Service Code
|
HCPCS 92012
|
| Hospital Charge Code |
42101200
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$107.01 |
| Max. Negotiated Rate |
$276.92 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$276.92
|
| 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 |
$233.00
|
| Rate for Payer: Cash Price |
$152.87
|
| 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 |
$204.58
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$173.89
|
| Rate for Payer: Elderplan Medicare Advantage |
$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 |
$250.00
|
| Rate for Payer: Group Health Inc Medicare |
$250.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$251.74
|
| 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: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$152.87
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$152.87
|
| Rate for Payer: United Healthcare Commercial |
$222.00
|
| 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
|
|
|
FOLLOW UP
|
Facility
|
IP
|
$503.49
|
|
|
Service Code
|
HCPCS 92012
|
| Hospital Charge Code |
42101200
|
|
Hospital Revenue Code
|
510
|
| Rate for Payer: Cash Price |
$152.87
|
|
|
FOMEPIZOLE 1000 MG/ML INJ 1.5 ML
|
Facility
|
IP
|
$26.24
|
|
|
Service Code
|
HCPCS J1451
|
| Hospital Charge Code |
41641892
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.12 |
| Max. Negotiated Rate |
$13.12 |
| Rate for Payer: Cash Price |
$6.06
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$13.12
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$13.12
|
|
|
FOMEPIZOLE 1000 MG/ML INJ 1.5 ML
|
Facility
|
IP
|
$26.24
|
|
|
Service Code
|
HCPCS J1451
|
| Hospital Charge Code |
41651892
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.12 |
| Max. Negotiated Rate |
$13.12 |
| Rate for Payer: Cash Price |
$6.06
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$13.12
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$13.12
|
|
|
FOMEPIZOLE 1000 MG/ML INJ 1.5 ML
|
Facility
|
OP
|
$26.24
|
|
|
Service Code
|
HCPCS J1451
|
| Hospital Charge Code |
41641892
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.24 |
| Max. Negotiated Rate |
$17.06 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$14.43
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$6.06
|
| Rate for Payer: Aetna Government |
$6.06
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$4.24
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$4.24
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$4.24
|
| Rate for Payer: Brighton Health Commercial |
$15.74
|
| Rate for Payer: Cash Price |
$6.06
|
| Rate for Payer: Cash Price |
$6.06
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$6.06
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$13.12
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$15.09
|
| Rate for Payer: Elderplan Medicare Advantage |
$6.06
|
| Rate for Payer: EmblemHealth Commercial |
$6.06
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$6.06
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$6.06
|
| Rate for Payer: Fidelis Essential Plan QHP |
$6.36
|
| Rate for Payer: Fidelis Medicare Advantage |
$6.06
|
| Rate for Payer: Fidelis Qualified Health Plan |
$6.36
|
| Rate for Payer: Group Health Inc Commercial |
$6.06
|
| Rate for Payer: Group Health Inc Medicare |
$6.06
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$13.12
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$13.12
|
| Rate for Payer: Healthfirst Medicare Advantage |
$5.15
|
| Rate for Payer: Healthfirst QHP |
$6.06
|
| Rate for Payer: Humana Medicare |
$6.18
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$6.06
|
| Rate for Payer: United Healthcare Commercial |
$7.22
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6.06
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$17.06
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$4.84
|
| Rate for Payer: Wellcare Medicare |
$5.75
|
|
