|
FOSFOMYCIN TROMETHAMINE 3 G PO PACK [14825]
|
Facility
|
OP
|
$100.40
|
|
|
Service Code
|
NDC 70700026894
|
| Hospital Charge Code |
70700026894
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$35.14 |
| Max. Negotiated Rate |
$80.32 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$55.22
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$50.20
|
| Rate for Payer: Aetna Government |
$50.20
|
| Rate for Payer: Brighton Health Commercial |
$75.30
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$80.32
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$68.27
|
| Rate for Payer: Group Health Inc Commercial |
$50.20
|
| Rate for Payer: Group Health Inc Medicare |
$35.14
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$50.20
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$50.20
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$65.26
|
|
|
FOSPHENYTOIN 50 MG/ML INJ 10 ML
|
Facility
|
OP
|
$3.04
|
|
|
Service Code
|
HCPCS Q2009
|
| Hospital Charge Code |
41652038
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.52 |
| Max. Negotiated Rate |
$5.04 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.67
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$4.80
|
| Rate for Payer: Aetna Government |
$4.80
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$3.36
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$3.36
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$3.36
|
| Rate for Payer: Brighton Health Commercial |
$1.82
|
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$4.80
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.52
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.75
|
| Rate for Payer: Elderplan Medicare Advantage |
$4.80
|
| Rate for Payer: EmblemHealth Commercial |
$4.80
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$4.80
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$4.80
|
| Rate for Payer: Fidelis Essential Plan QHP |
$5.04
|
| Rate for Payer: Fidelis Medicare Advantage |
$4.80
|
| Rate for Payer: Fidelis Qualified Health Plan |
$5.04
|
| Rate for Payer: Group Health Inc Commercial |
$4.80
|
| Rate for Payer: Group Health Inc Medicare |
$4.80
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.52
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.52
|
| Rate for Payer: Healthfirst Medicare Advantage |
$4.08
|
| Rate for Payer: Healthfirst QHP |
$4.80
|
| Rate for Payer: Humana Medicare |
$4.90
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$4.80
|
| Rate for Payer: United Healthcare Medicare Advantage |
$4.80
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.98
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$3.84
|
| Rate for Payer: Wellcare Medicare |
$4.56
|
|
|
FOSPHENYTOIN 50 MG/ML INJ 10 ML
|
Facility
|
IP
|
$3.04
|
|
|
Service Code
|
HCPCS Q2009
|
| Hospital Charge Code |
41642038
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.52 |
| Max. Negotiated Rate |
$1.52 |
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.52
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.52
|
|
|
FOSPHENYTOIN 50 MG/ML INJ 10 ML
|
Facility
|
IP
|
$3.04
|
|
|
Service Code
|
HCPCS Q2009
|
| Hospital Charge Code |
41652038
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.52 |
| Max. Negotiated Rate |
$1.52 |
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.52
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.52
|
|
|
FOSPHENYTOIN 50 MG/ML INJ 10 ML
|
Facility
|
OP
|
$3.04
|
|
|
Service Code
|
HCPCS Q2009
|
| Hospital Charge Code |
41642038
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.52 |
| Max. Negotiated Rate |
$5.04 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.67
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$4.80
|
| Rate for Payer: Aetna Government |
$4.80
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$3.36
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$3.36
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$3.36
|
| Rate for Payer: Brighton Health Commercial |
$1.82
|
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$4.80
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.52
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.75
|
| Rate for Payer: Elderplan Medicare Advantage |
$4.80
|
| Rate for Payer: EmblemHealth Commercial |
$4.80
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$4.80
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$4.80
|
| Rate for Payer: Fidelis Essential Plan QHP |
$5.04
|
| Rate for Payer: Fidelis Medicare Advantage |
$4.80
|
| Rate for Payer: Fidelis Qualified Health Plan |
$5.04
|
| Rate for Payer: Group Health Inc Commercial |
$4.80
|
| Rate for Payer: Group Health Inc Medicare |
$4.80
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.52
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.52
|
| Rate for Payer: Healthfirst Medicare Advantage |
$4.08
|
| Rate for Payer: Healthfirst QHP |
$4.80
|
| Rate for Payer: Humana Medicare |
$4.90
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$4.80
|
| Rate for Payer: United Healthcare Medicare Advantage |
$4.80
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.98
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$3.84
|
| Rate for Payer: Wellcare Medicare |
$4.56
|
|
|
FOSPHENYTOIN 50 MG/ML INJ 2 ML
|
Facility
|
IP
|
$3.73
|
|
|
Service Code
|
HCPCS Q2009
|
| Hospital Charge Code |
41641844
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.86 |
| Max. Negotiated Rate |
$1.86 |
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.86
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.86
|
|
|
FOSPHENYTOIN 50 MG/ML INJ 2 ML
|
Facility
|
OP
|
$3.73
|
|
|
Service Code
|
HCPCS Q2009
|
| Hospital Charge Code |
41651844
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.86 |
| Max. Negotiated Rate |
$5.04 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2.05
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$4.80
|
| Rate for Payer: Aetna Government |
$4.80
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$3.36
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$3.36
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$3.36
|
| Rate for Payer: Brighton Health Commercial |
$2.24
|
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$4.80
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.86
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2.14
|
| Rate for Payer: Elderplan Medicare Advantage |
$4.80
|
| Rate for Payer: EmblemHealth Commercial |
$4.80
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$4.80
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$4.80
|
| Rate for Payer: Fidelis Essential Plan QHP |
$5.04
|
| Rate for Payer: Fidelis Medicare Advantage |
$4.80
|
| Rate for Payer: Fidelis Qualified Health Plan |
$5.04
|
| Rate for Payer: Group Health Inc Commercial |
$4.80
|
| Rate for Payer: Group Health Inc Medicare |
$4.80
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.86
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.86
|
| Rate for Payer: Healthfirst Medicare Advantage |
$4.08
|
| Rate for Payer: Healthfirst QHP |
$4.80
|
| Rate for Payer: Humana Medicare |
$4.90
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$4.80
|
| Rate for Payer: United Healthcare Medicare Advantage |
$4.80
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2.42
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$3.84
|
| Rate for Payer: Wellcare Medicare |
$4.56
|
|
|
FOSPHENYTOIN 50 MG/ML INJ 2 ML
|
Facility
|
IP
|
$3.73
|
|
|
Service Code
|
HCPCS Q2009
|
| Hospital Charge Code |
41651844
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.86 |
| Max. Negotiated Rate |
$1.86 |
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.86
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.86
|
|
|
FOSPHENYTOIN 50 MG/ML INJ 2 ML
|
Facility
|
OP
|
$3.73
|
|
|
Service Code
|
HCPCS Q2009
|
| Hospital Charge Code |
41641844
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.86 |
| Max. Negotiated Rate |
$5.04 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2.05
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$4.80
|
| Rate for Payer: Aetna Government |
$4.80
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$3.36
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$3.36
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$3.36
|
| Rate for Payer: Brighton Health Commercial |
$2.24
|
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$4.80
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.86
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2.14
|
| Rate for Payer: Elderplan Medicare Advantage |
$4.80
|
| Rate for Payer: EmblemHealth Commercial |
$4.80
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$4.80
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$4.80
|
| Rate for Payer: Fidelis Essential Plan QHP |
$5.04
|
| Rate for Payer: Fidelis Medicare Advantage |
$4.80
|
| Rate for Payer: Fidelis Qualified Health Plan |
$5.04
|
| Rate for Payer: Group Health Inc Commercial |
$4.80
|
| Rate for Payer: Group Health Inc Medicare |
$4.80
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.86
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.86
|
| Rate for Payer: Healthfirst Medicare Advantage |
$4.08
|
| Rate for Payer: Healthfirst QHP |
$4.80
|
| Rate for Payer: Humana Medicare |
$4.90
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$4.80
|
| Rate for Payer: United Healthcare Medicare Advantage |
$4.80
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2.42
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$3.84
|
| Rate for Payer: Wellcare Medicare |
$4.56
|
|
|
FOSPHENYTOIN SODIUM 100 MG PE/2ML IJ SOLN [88011]
|
Facility
|
OP
|
$24.26
|
|
|
Service Code
|
NDC 00069600125
|
| Hospital Charge Code |
00069600125
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.49 |
| Max. Negotiated Rate |
$19.41 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$13.34
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$12.13
|
| Rate for Payer: Aetna Government |
$12.13
|
| Rate for Payer: Brighton Health Commercial |
$18.19
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$19.41
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$16.50
|
| Rate for Payer: Group Health Inc Commercial |
$12.13
|
| Rate for Payer: Group Health Inc Medicare |
$8.49
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$12.13
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$12.13
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$15.77
|
|
|
FOSPHENYTOIN SODIUM 100 MG PE/2ML IJ SOLN [88011]
|
Facility
|
OP
|
$8.88
|
|
|
Service Code
|
NDC 00641613601
|
| Hospital Charge Code |
00641613601
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.11 |
| Max. Negotiated Rate |
$7.10 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$4.88
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$4.44
|
| Rate for Payer: Aetna Government |
$4.44
|
| Rate for Payer: Brighton Health Commercial |
$6.66
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$7.10
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$6.04
|
| Rate for Payer: Group Health Inc Commercial |
$4.44
|
| Rate for Payer: Group Health Inc Medicare |
$3.11
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4.44
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4.44
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$5.77
|
|
|
FOSPHENYTOIN SODIUM 500 MG PE/10ML IJ SOLN [88010]
|
Facility
|
OP
|
$5.70
|
|
|
Service Code
|
NDC 00641613701
|
| Hospital Charge Code |
00641613701
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.00 |
| Max. Negotiated Rate |
$4.56 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$3.14
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.85
|
| Rate for Payer: Aetna Government |
$2.85
|
| Rate for Payer: Brighton Health Commercial |
$4.28
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$4.56
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$3.88
|
| Rate for Payer: Group Health Inc Commercial |
$2.85
|
| Rate for Payer: Group Health Inc Medicare |
$2.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.85
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2.85
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3.70
|
|
|
FOSPHENYTOIN SODIUM 500 MG PE/10ML IJ SOLN [88010]
|
Facility
|
OP
|
$14.56
|
|
|
Service Code
|
NDC 00069600121
|
| Hospital Charge Code |
00069600121
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.09 |
| Max. Negotiated Rate |
$11.64 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$8.01
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$7.28
|
| Rate for Payer: Aetna Government |
$7.28
|
| Rate for Payer: Brighton Health Commercial |
$10.92
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$11.64
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$9.90
|
| Rate for Payer: Group Health Inc Commercial |
$7.28
|
| Rate for Payer: Group Health Inc Medicare |
$5.09
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$7.28
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$7.28
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$9.46
|
|
|
FOSPHENYTOIN SODIUM 500 MG PE/10ML IJ SOLN [88010]
|
Facility
|
OP
|
$14.56
|
|
|
Service Code
|
NDC 00069600110
|
| Hospital Charge Code |
00069600110
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.09 |
| Max. Negotiated Rate |
$11.64 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$8.01
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$7.28
|
| Rate for Payer: Aetna Government |
$7.28
|
| Rate for Payer: Brighton Health Commercial |
$10.92
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$11.64
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$9.90
|
| Rate for Payer: Group Health Inc Commercial |
$7.28
|
| Rate for Payer: Group Health Inc Medicare |
$5.09
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$7.28
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$7.28
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$9.46
|
|
|
FOSTEMSAVIR TROMETHAMINE
|
Facility
|
OP
|
$382.50
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
41640375
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$133.88 |
| Max. Negotiated Rate |
$248.62 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$210.38
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$191.25
|
| Rate for Payer: Aetna Government |
$191.25
|
| Rate for Payer: Brighton Health Commercial |
$229.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$191.25
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$219.94
|
| Rate for Payer: Group Health Inc Commercial |
$191.25
|
| Rate for Payer: Group Health Inc Medicare |
$133.88
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$191.25
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$191.25
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$248.62
|
|
|
FOSTEMSAVIR TROMETHAMINE
|
Facility
|
IP
|
$382.50
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
41650375
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$191.25 |
| Max. Negotiated Rate |
$191.25 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$191.25
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$191.25
|
|
|
FOSTEMSAVIR TROMETHAMINE
|
Facility
|
IP
|
$382.50
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
41640375
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$191.25 |
| Max. Negotiated Rate |
$191.25 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$191.25
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$191.25
|
|
|
FOSTEMSAVIR TROMETHAMINE
|
Facility
|
OP
|
$382.50
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
41650375
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$133.88 |
| Max. Negotiated Rate |
$248.62 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$210.38
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$191.25
|
| Rate for Payer: Aetna Government |
$191.25
|
| Rate for Payer: Brighton Health Commercial |
$229.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$191.25
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$219.94
|
| Rate for Payer: Group Health Inc Commercial |
$191.25
|
| Rate for Payer: Group Health Inc Medicare |
$133.88
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$191.25
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$191.25
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$248.62
|
|
|
FOSTEMSAVIR TROMETHAMINE ER 600 MG PO TB12 [174484]
|
Facility
|
OP
|
$180.20
|
|
|
Service Code
|
NDC 49702025018
|
| Hospital Charge Code |
49702025018
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$63.07 |
| Max. Negotiated Rate |
$144.16 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$99.11
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$90.10
|
| Rate for Payer: Aetna Government |
$90.10
|
| Rate for Payer: Brighton Health Commercial |
$135.15
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$144.16
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$122.54
|
| Rate for Payer: Group Health Inc Commercial |
$90.10
|
| Rate for Payer: Group Health Inc Medicare |
$63.07
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$90.10
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$90.10
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$117.13
|
|
|
FOUR BY FOUR
|
Facility
|
OP
|
$0.36
|
|
| Hospital Charge Code |
40201850
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.20
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.18
|
| Rate for Payer: Aetna Government |
$0.18
|
| Rate for Payer: Brighton Health Commercial |
$0.27
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.29
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.24
|
| Rate for Payer: Group Health Inc Commercial |
$0.18
|
| Rate for Payer: Group Health Inc Medicare |
$0.13
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.18
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.18
|
|
|
FRACTURE 2.4 PLATE 4 HOLE 28MM
|
Facility
|
OP
|
$340.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
40209396
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$119.00 |
| Max. Negotiated Rate |
$357.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$187.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$134.20
|
| Rate for Payer: Aetna Government |
$134.20
|
| Rate for Payer: Brighton Health Commercial |
$204.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$170.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$195.50
|
| Rate for Payer: EmblemHealth Commercial |
$170.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$357.00
|
| Rate for Payer: Group Health Inc Commercial |
$170.00
|
| Rate for Payer: Group Health Inc Medicare |
$119.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$170.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$170.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$221.00
|
|
|
FRACTURE 2.4 PLATE 4 HOLE 28MM
|
Facility
|
IP
|
$340.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
40209396
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$170.00 |
| Max. Negotiated Rate |
$170.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$170.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$170.00
|
|
|
Fracture Bed Pan
|
Facility
|
OP
|
$4.61
|
|
| Hospital Charge Code |
40201853
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$1.61 |
| Max. Negotiated Rate |
$3.69 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2.54
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.30
|
| Rate for Payer: Aetna Government |
$2.30
|
| Rate for Payer: Brighton Health Commercial |
$3.46
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$3.69
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$3.13
|
| Rate for Payer: Group Health Inc Commercial |
$2.30
|
| Rate for Payer: Group Health Inc Medicare |
$1.61
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.30
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2.30
|
|
|
FRACTURE PAN
|
Facility
|
OP
|
$23.39
|
|
| Hospital Charge Code |
40201855
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$8.19 |
| Max. Negotiated Rate |
$18.71 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$12.86
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$11.70
|
| Rate for Payer: Aetna Government |
$11.70
|
| Rate for Payer: Brighton Health Commercial |
$17.54
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$18.71
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$15.91
|
| Rate for Payer: Group Health Inc Commercial |
$11.70
|
| Rate for Payer: Group Health Inc Medicare |
$8.19
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$11.70
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$11.70
|
|
|
FRACTURE PLATE -14 HOLE
|
Facility
|
OP
|
$1,102.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
40201346
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$134.20 |
| Max. Negotiated Rate |
$1,157.10 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$606.10
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$134.20
|
| Rate for Payer: Aetna Government |
$134.20
|
| Rate for Payer: Brighton Health Commercial |
$661.20
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$551.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$633.65
|
| Rate for Payer: EmblemHealth Commercial |
$551.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,157.10
|
| Rate for Payer: Group Health Inc Commercial |
$551.00
|
| Rate for Payer: Group Health Inc Medicare |
$385.70
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$551.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$551.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$716.30
|
|
