|
FORMULA PEDIALYTE 2 OZ. BTL.
|
Facility
|
OP
|
$1.85
|
|
| Hospital Charge Code |
64902356
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$1.48 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.02
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.93
|
| Rate for Payer: Aetna Government |
$0.93
|
| Rate for Payer: Brighton Health Commercial |
$1.39
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.48
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.26
|
| Rate for Payer: Group Health Inc Commercial |
$0.93
|
| Rate for Payer: Group Health Inc Medicare |
$0.65
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.93
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.93
|
|
|
FORMULA PEDIALYTE FREEZER POPS
|
Facility
|
OP
|
$0.75
|
|
| Hospital Charge Code |
64901107
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$0.60 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.41
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.38
|
| Rate for Payer: Aetna Government |
$0.38
|
| Rate for Payer: Brighton Health Commercial |
$0.56
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.60
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.51
|
| Rate for Payer: Group Health Inc Commercial |
$0.38
|
| Rate for Payer: Group Health Inc Medicare |
$0.26
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.38
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.38
|
|
|
FORMULA SIMILAC 24 HIGH PROTEIN
|
Facility
|
OP
|
$4.03
|
|
| Hospital Charge Code |
64902364
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$1.41 |
| Max. Negotiated Rate |
$3.22 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2.22
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.02
|
| Rate for Payer: Aetna Government |
$2.02
|
| Rate for Payer: Brighton Health Commercial |
$3.02
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$3.22
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2.74
|
| Rate for Payer: Group Health Inc Commercial |
$2.02
|
| Rate for Payer: Group Health Inc Medicare |
$1.41
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.02
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2.02
|
|
|
FORMULA SIMILAC 2 OZ. 5% GLUCOS
|
Facility
|
OP
|
$1.13
|
|
| Hospital Charge Code |
64902344
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$0.40 |
| Max. Negotiated Rate |
$0.90 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.62
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.57
|
| Rate for Payer: Aetna Government |
$0.57
|
| Rate for Payer: Brighton Health Commercial |
$0.85
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.90
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.77
|
| Rate for Payer: Group Health Inc Commercial |
$0.57
|
| Rate for Payer: Group Health Inc Medicare |
$0.40
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.57
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.57
|
|
|
FORMULA SIMILAC ADVAN EARLY
|
Facility
|
OP
|
$0.12
|
|
| Hospital Charge Code |
64902346
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.10 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.07
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.06
|
| Rate for Payer: Aetna Government |
$0.06
|
| Rate for Payer: Brighton Health Commercial |
$0.09
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.10
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.08
|
| 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
|
|
|
FORMULA SIMILAC HUMAN MLK FORTIFR
|
Facility
|
OP
|
$208.78
|
|
| Hospital Charge Code |
64902409
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$73.07 |
| Max. Negotiated Rate |
$167.02 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$114.83
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$104.39
|
| Rate for Payer: Aetna Government |
$104.39
|
| Rate for Payer: Brighton Health Commercial |
$156.58
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$167.02
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$141.97
|
| Rate for Payer: Group Health Inc Commercial |
$104.39
|
| Rate for Payer: Group Health Inc Medicare |
$73.07
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$104.39
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$104.39
|
|
|
FORMULA SIMILAC SPECIAL CARE
|
Facility
|
OP
|
$4.03
|
|
| Hospital Charge Code |
64902370
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$1.41 |
| Max. Negotiated Rate |
$3.22 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2.22
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.02
|
| Rate for Payer: Aetna Government |
$2.02
|
| Rate for Payer: Brighton Health Commercial |
$3.02
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$3.22
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2.74
|
| Rate for Payer: Group Health Inc Commercial |
$2.02
|
| Rate for Payer: Group Health Inc Medicare |
$1.41
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.02
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2.02
|
|
|
FORMULA SOY PROSOBEE
|
Facility
|
OP
|
$1.68
|
|
| Hospital Charge Code |
64902372
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$1.34 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.92
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.84
|
| Rate for Payer: Aetna Government |
$0.84
|
| Rate for Payer: Brighton Health Commercial |
$1.26
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.34
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.14
|
| Rate for Payer: Group Health Inc Commercial |
$0.84
|
| Rate for Payer: Group Health Inc Medicare |
$0.59
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.84
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.84
|
|
|
FORMULA TOMCAT 5.0MM
|
Facility
|
OP
|
$500.00
|
|
| Hospital Charge Code |
64905914
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$175.00 |
| Max. Negotiated Rate |
$400.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$275.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$250.00
|
| Rate for Payer: Aetna Government |
$250.00
|
| Rate for Payer: Brighton Health Commercial |
$375.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$400.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$340.00
|
| Rate for Payer: Group Health Inc Commercial |
$250.00
|
| Rate for Payer: Group Health Inc Medicare |
$175.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$250.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$250.00
|
|
|
FORMULA WATER STERILIZED
|
Facility
|
OP
|
$1.13
|
|
| Hospital Charge Code |
64902342
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$0.40 |
| Max. Negotiated Rate |
$0.90 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.62
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.57
|
| Rate for Payer: Aetna Government |
$0.57
|
| Rate for Payer: Brighton Health Commercial |
$0.85
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.90
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.77
|
| Rate for Payer: Group Health Inc Commercial |
$0.57
|
| Rate for Payer: Group Health Inc Medicare |
$0.40
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.57
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.57
|
|
|
FORTIFIER ENFAMIL HUMAN MILK
|
Facility
|
OP
|
$3.44
|
|
| Hospital Charge Code |
64903000
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$1.20 |
| Max. Negotiated Rate |
$2.75 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.89
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.72
|
| Rate for Payer: Aetna Government |
$1.72
|
| Rate for Payer: Brighton Health Commercial |
$2.58
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2.75
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2.34
|
| Rate for Payer: Group Health Inc Commercial |
$1.72
|
| Rate for Payer: Group Health Inc Medicare |
$1.20
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.72
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.72
|
|
|
FOSAMPRENAVIR 700 MG TAB
|
Facility
|
OP
|
$26.03
|
|
| Hospital Charge Code |
41653306
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.11 |
| Max. Negotiated Rate |
$20.82 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$14.32
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$13.02
|
| Rate for Payer: Aetna Government |
$13.02
|
| Rate for Payer: Brighton Health Commercial |
$19.52
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$20.82
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$17.70
|
| Rate for Payer: Group Health Inc Commercial |
$13.02
|
| Rate for Payer: Group Health Inc Medicare |
$9.11
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$13.02
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$13.02
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$16.92
|
|
|
FOSAMPRENAVIR 700 MG TAB
|
Facility
|
OP
|
$26.03
|
|
| Hospital Charge Code |
41643306
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.11 |
| Max. Negotiated Rate |
$20.82 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$14.32
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$13.02
|
| Rate for Payer: Aetna Government |
$13.02
|
| Rate for Payer: Brighton Health Commercial |
$19.52
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$20.82
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$17.70
|
| Rate for Payer: Group Health Inc Commercial |
$13.02
|
| Rate for Payer: Group Health Inc Medicare |
$9.11
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$13.02
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$13.02
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$16.92
|
|
|
FOSAMPRENAVIR CALCIUM 700 MG PO TABS [37182]
|
Facility
|
OP
|
$20.83
|
|
|
Service Code
|
NDC 63304058360
|
| Hospital Charge Code |
63304058360
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.29 |
| Max. Negotiated Rate |
$16.66 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$11.46
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$10.42
|
| Rate for Payer: Aetna Government |
$10.42
|
| Rate for Payer: Brighton Health Commercial |
$15.62
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$16.66
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$14.17
|
| Rate for Payer: Group Health Inc Commercial |
$10.42
|
| Rate for Payer: Group Health Inc Medicare |
$7.29
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$10.42
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$10.42
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$13.54
|
|
|
FOSAMPRENAVIR CALCIUM 700 MG PO TABS [37182]
|
Facility
|
OP
|
$23.17
|
|
|
Service Code
|
NDC 49702020718
|
| Hospital Charge Code |
49702020718
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.11 |
| Max. Negotiated Rate |
$18.54 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$12.74
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$11.59
|
| Rate for Payer: Aetna Government |
$11.59
|
| Rate for Payer: Brighton Health Commercial |
$17.38
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$18.54
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$15.76
|
| Rate for Payer: Group Health Inc Commercial |
$11.59
|
| Rate for Payer: Group Health Inc Medicare |
$8.11
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$11.59
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$11.59
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$15.06
|
|
|
FOSAPREPITANT DIMEGLUMINE 150 MG IV SOLR [106783]
|
Facility
|
OP
|
$321.75
|
|
|
Service Code
|
HCPCS J1453
|
| Hospital Charge Code |
31722016531
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$337.84 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$176.96
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.24
|
| Rate for Payer: Aetna Government |
$0.24
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$3.94
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$3.94
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$1.75
|
| Rate for Payer: Amida Care Medicaid |
$1.75
|
| Rate for Payer: Brighton Health Commercial |
$193.05
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$160.88
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$185.01
|
| Rate for Payer: EmblemHealth Commercial |
$160.88
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$175.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$1.75
|
| Rate for Payer: Fidelis Essential Plan QHP |
$1.75
|
| Rate for Payer: Fidelis Medicare Advantage |
$337.84
|
| Rate for Payer: Fidelis Qualified Health Plan |
$1.84
|
| Rate for Payer: Group Health Inc Commercial |
$160.88
|
| Rate for Payer: Group Health Inc Medicare |
$112.61
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.75
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$160.88
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$1.75
|
| Rate for Payer: Healthfirst Essential Plan |
$3.94
|
| Rate for Payer: Healthfirst QHP |
$1.75
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$1.75
|
| Rate for Payer: SOMOS Essential |
$1.75
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$3.94
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$1.92
|
| Rate for Payer: United Healthcare Medicaid |
$1.75
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$209.14
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$1.75
|
|
|
FOSAPREPITANT DIMEGLUMINE 150 MG IV SOLR [106783]
|
Facility
|
OP
|
$401.56
|
|
|
Service Code
|
HCPCS J1453
|
| Hospital Charge Code |
00006306100
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$421.64 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$220.86
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.24
|
| Rate for Payer: Aetna Government |
$0.24
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$3.94
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$3.94
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$1.75
|
| Rate for Payer: Amida Care Medicaid |
$1.75
|
| Rate for Payer: Brighton Health Commercial |
$240.94
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$200.78
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$230.90
|
| Rate for Payer: EmblemHealth Commercial |
$200.78
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$175.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$1.75
|
| Rate for Payer: Fidelis Essential Plan QHP |
$1.75
|
| Rate for Payer: Fidelis Medicare Advantage |
$421.64
|
| Rate for Payer: Fidelis Qualified Health Plan |
$1.84
|
| Rate for Payer: Group Health Inc Commercial |
$200.78
|
| Rate for Payer: Group Health Inc Medicare |
$140.55
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.75
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$200.78
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$1.75
|
| Rate for Payer: Healthfirst Essential Plan |
$3.94
|
| Rate for Payer: Healthfirst QHP |
$1.75
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$1.75
|
| Rate for Payer: SOMOS Essential |
$1.75
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$3.94
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$1.92
|
| Rate for Payer: United Healthcare Medicaid |
$1.75
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$261.01
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$1.75
|
|
|
FOSAPREPITANT DIMEGLUMINE 150 MG IV SOLR [106783]
|
Facility
|
IP
|
$401.56
|
|
|
Service Code
|
HCPCS J1453
|
| Hospital Charge Code |
00006306100
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$200.78 |
| Max. Negotiated Rate |
$200.78 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$200.78
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$200.78
|
|
|
FOSAPREPITANT DIMEGLUMINE 150 MG IV SOLR [106783]
|
Facility
|
IP
|
$321.75
|
|
|
Service Code
|
HCPCS J1453
|
| Hospital Charge Code |
31722016531
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$160.88 |
| Max. Negotiated Rate |
$160.88 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$160.88
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$160.88
|
|
|
FOSCARNET 24 MG/ML INJ
|
Facility
|
OP
|
$123.00
|
|
|
Service Code
|
HCPCS J1455
|
| Hospital Charge Code |
41644567
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$41.56 |
| Max. Negotiated Rate |
$79.95 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$67.65
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$59.37
|
| Rate for Payer: Aetna Government |
$59.37
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$41.56
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$41.56
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$41.56
|
| Rate for Payer: Brighton Health Commercial |
$73.80
|
| Rate for Payer: Cash Price |
$59.37
|
| Rate for Payer: Cash Price |
$59.37
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$59.37
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$61.50
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$70.72
|
| Rate for Payer: Elderplan Medicare Advantage |
$59.37
|
| Rate for Payer: EmblemHealth Commercial |
$59.37
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$59.37
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$59.37
|
| Rate for Payer: Fidelis Essential Plan QHP |
$62.34
|
| Rate for Payer: Fidelis Medicare Advantage |
$59.37
|
| Rate for Payer: Fidelis Qualified Health Plan |
$62.34
|
| Rate for Payer: Group Health Inc Commercial |
$59.37
|
| Rate for Payer: Group Health Inc Medicare |
$59.37
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$61.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$61.50
|
| Rate for Payer: Healthfirst Medicare Advantage |
$50.46
|
| Rate for Payer: Healthfirst QHP |
$59.37
|
| Rate for Payer: Humana Medicare |
$60.56
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$59.37
|
| Rate for Payer: United Healthcare Commercial |
$67.52
|
| Rate for Payer: United Healthcare Medicare Advantage |
$59.37
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$79.95
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$47.50
|
| Rate for Payer: Wellcare Medicare |
$56.40
|
|
|
FOSCARNET 24 MG/ML INJ
|
Facility
|
IP
|
$123.00
|
|
|
Service Code
|
HCPCS J1455
|
| Hospital Charge Code |
41654567
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$61.50 |
| Max. Negotiated Rate |
$61.50 |
| Rate for Payer: Cash Price |
$59.37
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$61.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$61.50
|
|
|
FOSCARNET 24 MG/ML INJ
|
Facility
|
OP
|
$123.00
|
|
|
Service Code
|
HCPCS J1455
|
| Hospital Charge Code |
41654567
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$41.56 |
| Max. Negotiated Rate |
$79.95 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$67.65
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$59.37
|
| Rate for Payer: Aetna Government |
$59.37
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$41.56
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$41.56
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$41.56
|
| Rate for Payer: Brighton Health Commercial |
$73.80
|
| Rate for Payer: Cash Price |
$59.37
|
| Rate for Payer: Cash Price |
$59.37
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$59.37
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$61.50
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$70.72
|
| Rate for Payer: Elderplan Medicare Advantage |
$59.37
|
| Rate for Payer: EmblemHealth Commercial |
$59.37
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$59.37
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$59.37
|
| Rate for Payer: Fidelis Essential Plan QHP |
$62.34
|
| Rate for Payer: Fidelis Medicare Advantage |
$59.37
|
| Rate for Payer: Fidelis Qualified Health Plan |
$62.34
|
| Rate for Payer: Group Health Inc Commercial |
$59.37
|
| Rate for Payer: Group Health Inc Medicare |
$59.37
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$61.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$61.50
|
| Rate for Payer: Healthfirst Medicare Advantage |
$50.46
|
| Rate for Payer: Healthfirst QHP |
$59.37
|
| Rate for Payer: Humana Medicare |
$60.56
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$59.37
|
| Rate for Payer: United Healthcare Commercial |
$67.52
|
| Rate for Payer: United Healthcare Medicare Advantage |
$59.37
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$79.95
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$47.50
|
| Rate for Payer: Wellcare Medicare |
$56.40
|
|
|
FOSCARNET 24 MG/ML INJ
|
Facility
|
IP
|
$123.00
|
|
|
Service Code
|
HCPCS J1455
|
| Hospital Charge Code |
41644567
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$61.50 |
| Max. Negotiated Rate |
$61.50 |
| Rate for Payer: Cash Price |
$59.37
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$61.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$61.50
|
|
|
FOSFOMYCIN 3 G ORAL
|
Facility
|
OP
|
$33.00
|
|
| Hospital Charge Code |
41645973
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.55 |
| Max. Negotiated Rate |
$26.40 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$18.15
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$16.50
|
| Rate for Payer: Aetna Government |
$16.50
|
| Rate for Payer: Brighton Health Commercial |
$24.75
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$26.40
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$22.44
|
| Rate for Payer: Group Health Inc Commercial |
$16.50
|
| Rate for Payer: Group Health Inc Medicare |
$11.55
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$16.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$16.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$21.45
|
|
|
FOSFOMYCIN 3 G ORAL
|
Facility
|
OP
|
$33.00
|
|
| Hospital Charge Code |
41655973
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.55 |
| Max. Negotiated Rate |
$26.40 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$18.15
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$16.50
|
| Rate for Payer: Aetna Government |
$16.50
|
| Rate for Payer: Brighton Health Commercial |
$24.75
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$26.40
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$22.44
|
| Rate for Payer: Group Health Inc Commercial |
$16.50
|
| Rate for Payer: Group Health Inc Medicare |
$11.55
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$16.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$16.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$21.45
|
|
