|
AMLODIPINE BESYLATE 10 MG PO TABS [9069]
|
Facility
|
OP
|
$2.38
|
|
|
Service Code
|
NDC 67877019990
|
| Hospital Charge Code |
67877019990
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.83 |
| Max. Negotiated Rate |
$1.91 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.31
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.19
|
| Rate for Payer: Aetna Government |
$1.19
|
| Rate for Payer: Brighton Health Commercial |
$1.79
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.91
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.62
|
| Rate for Payer: Group Health Inc Commercial |
$1.19
|
| Rate for Payer: Group Health Inc Medicare |
$0.83
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.19
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.19
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.55
|
|
|
AMLODIPINE BESYLATE 10 MG PO TABS [9069]
|
Facility
|
OP
|
$2.26
|
|
|
Service Code
|
NDC 00904637161
|
| Hospital Charge Code |
00904637161
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.79 |
| Max. Negotiated Rate |
$1.80 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.24
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.13
|
| Rate for Payer: Aetna Government |
$1.13
|
| Rate for Payer: Brighton Health Commercial |
$1.69
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.80
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.53
|
| Rate for Payer: Group Health Inc Commercial |
$1.13
|
| Rate for Payer: Group Health Inc Medicare |
$0.79
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.13
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.13
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.47
|
|
|
AMLODIPINE BESYLATE 10 MG PO TABS [9069]
|
Facility
|
OP
|
$2.38
|
|
|
Service Code
|
NDC 67877019905
|
| Hospital Charge Code |
67877019905
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.83 |
| Max. Negotiated Rate |
$1.91 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.31
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.19
|
| Rate for Payer: Aetna Government |
$1.19
|
| Rate for Payer: Brighton Health Commercial |
$1.79
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.91
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.62
|
| Rate for Payer: Group Health Inc Commercial |
$1.19
|
| Rate for Payer: Group Health Inc Medicare |
$0.83
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.19
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.19
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.55
|
|
|
AMLODIPINE BESYLATE 10 MG PO TABS [9069]
|
Facility
|
OP
|
$2.38
|
|
|
Service Code
|
NDC 67877019910
|
| Hospital Charge Code |
67877019910
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.83 |
| Max. Negotiated Rate |
$1.91 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.31
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.19
|
| Rate for Payer: Aetna Government |
$1.19
|
| Rate for Payer: Brighton Health Commercial |
$1.79
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.91
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.62
|
| Rate for Payer: Group Health Inc Commercial |
$1.19
|
| Rate for Payer: Group Health Inc Medicare |
$0.83
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.19
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.19
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.55
|
|
|
AMLODIPINE BESYLATE 2.5 MG PO TABS [9070]
|
Facility
|
OP
|
$1.59
|
|
|
Service Code
|
NDC 00904636961
|
| Hospital Charge Code |
00904636961
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$1.27 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.88
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.80
|
| Rate for Payer: Aetna Government |
$0.80
|
| Rate for Payer: Brighton Health Commercial |
$1.19
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.27
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.08
|
| Rate for Payer: Group Health Inc Commercial |
$0.80
|
| Rate for Payer: Group Health Inc Medicare |
$0.56
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.80
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.80
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.04
|
|
|
AMLODIPINE BESYLATE 2.5 MG PO TABS [9070]
|
Facility
|
OP
|
$1.73
|
|
|
Service Code
|
NDC 69097012605
|
| Hospital Charge Code |
69097012605
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$1.38 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.95
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.87
|
| Rate for Payer: Aetna Government |
$0.87
|
| Rate for Payer: Brighton Health Commercial |
$1.30
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.38
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.18
|
| Rate for Payer: Group Health Inc Commercial |
$0.87
|
| Rate for Payer: Group Health Inc Medicare |
$0.61
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.87
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.87
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.12
|
|
|
AMLODIPINE BESYLATE 5 MG PO TABS [9071]
|
Facility
|
OP
|
$1.73
|
|
|
Service Code
|
NDC 69097012715
|
| Hospital Charge Code |
69097012715
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$1.38 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.95
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.87
|
| Rate for Payer: Aetna Government |
$0.87
|
| Rate for Payer: Brighton Health Commercial |
$1.30
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.38
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.18
|
| Rate for Payer: Group Health Inc Commercial |
$0.87
|
| Rate for Payer: Group Health Inc Medicare |
$0.61
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.87
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.87
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.12
|
|
|
AMLODIPINE BESYLATE 5 MG PO TABS [9071]
|
Facility
|
OP
|
$1.79
|
|
|
Service Code
|
NDC 67877019810
|
| Hospital Charge Code |
67877019810
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.63 |
| Max. Negotiated Rate |
$1.43 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.98
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.89
|
| Rate for Payer: Aetna Government |
$0.89
|
| Rate for Payer: Brighton Health Commercial |
$1.34
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.43
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.22
|
| Rate for Payer: Group Health Inc Commercial |
$0.89
|
| Rate for Payer: Group Health Inc Medicare |
$0.63
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.89
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.89
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.16
|
|
|
AMLODIPINE BESYLATE 5 MG PO TABS [9071]
|
Facility
|
OP
|
$1.79
|
|
|
Service Code
|
NDC 67877019890
|
| Hospital Charge Code |
67877019890
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.63 |
| Max. Negotiated Rate |
$1.43 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.98
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.89
|
| Rate for Payer: Aetna Government |
$0.89
|
| Rate for Payer: Brighton Health Commercial |
$1.34
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.43
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.22
|
| Rate for Payer: Group Health Inc Commercial |
$0.89
|
| Rate for Payer: Group Health Inc Medicare |
$0.63
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.89
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.89
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.16
|
|
|
AMLODIPINE BESYLATE 5 MG PO TABS [9071]
|
Facility
|
OP
|
$10.17
|
|
|
Service Code
|
NDC 00069153041
|
| Hospital Charge Code |
00069153041
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.56 |
| Max. Negotiated Rate |
$8.13 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$5.59
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$5.08
|
| Rate for Payer: Aetna Government |
$5.08
|
| Rate for Payer: Brighton Health Commercial |
$7.62
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$8.13
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$6.91
|
| Rate for Payer: Group Health Inc Commercial |
$5.08
|
| Rate for Payer: Group Health Inc Medicare |
$3.56
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$5.08
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$5.08
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$6.61
|
|
|
AMLODIPINE BESYLATE 5 MG PO TABS [9071]
|
Facility
|
OP
|
$1.64
|
|
|
Service Code
|
NDC 00904637061
|
| Hospital Charge Code |
00904637061
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$1.31 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.90
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.82
|
| Rate for Payer: Aetna Government |
$0.82
|
| Rate for Payer: Brighton Health Commercial |
$1.23
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.31
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.12
|
| Rate for Payer: Group Health Inc Commercial |
$0.82
|
| Rate for Payer: Group Health Inc Medicare |
$0.58
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.82
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.82
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.07
|
|
|
AMLODIPINE BESYLATE 5 MG PO TABS [9071]
|
Facility
|
OP
|
$0.19
|
|
|
Service Code
|
NDC 60687048801
|
| Hospital Charge Code |
60687048801
|
|
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 |
$0.09
|
| Rate for Payer: Aetna Government |
$0.09
|
| 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 |
$0.09
|
| Rate for Payer: Group Health Inc Medicare |
$0.07
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.09
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.09
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.12
|
|
|
AMMONIA 2% INHALANT
|
Facility
|
OP
|
$1.00
|
|
| Hospital Charge Code |
41653460
|
|
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
|
|
|
AMMONIA 2% INHALANT
|
Facility
|
OP
|
$1.00
|
|
| Hospital Charge Code |
41643460
|
|
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
|
|
|
AMMONIA AROMATIC IN INHA [439]
|
Facility
|
OP
|
$0.27
|
|
|
Service Code
|
NDC 67777025101
|
| Hospital Charge Code |
67777025101
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.15
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.13
|
| Rate for Payer: Aetna Government |
$0.13
|
| Rate for Payer: Brighton Health Commercial |
$0.20
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.22
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.18
|
| Rate for Payer: Group Health Inc Commercial |
$0.13
|
| Rate for Payer: Group Health Inc Medicare |
$0.09
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.13
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.13
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.17
|
|
|
AMMONIA BLOOD
|
Facility
|
IP
|
$36.43
|
|
|
Service Code
|
HCPCS 82140
|
| Hospital Charge Code |
40602165
|
|
Hospital Revenue Code
|
301
|
| Rate for Payer: Cash Price |
$14.57
|
|
|
AMMONIA BLOOD
|
Facility
|
OP
|
$36.43
|
|
|
Service Code
|
HCPCS 82140
|
| Hospital Charge Code |
40602165
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$10.20 |
| Max. Negotiated Rate |
$27.32 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$20.04
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$14.57
|
| Rate for Payer: Aetna Government |
$14.57
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$10.20
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$10.20
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$10.20
|
| Rate for Payer: Brighton Health Commercial |
$27.32
|
| Rate for Payer: Cash Price |
$14.57
|
| Rate for Payer: Cash Price |
$14.57
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$14.57
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$23.17
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$19.60
|
| Rate for Payer: Elderplan Medicare Advantage |
$14.57
|
| Rate for Payer: EmblemHealth Commercial |
$14.57
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$12.38
|
| Rate for Payer: Fidelis Essential Plan QHP |
$12.97
|
| Rate for Payer: Fidelis Medicare Advantage |
$14.57
|
| Rate for Payer: Fidelis Qualified Health Plan |
$12.97
|
| Rate for Payer: Group Health Inc Commercial |
$14.57
|
| Rate for Payer: Group Health Inc Medicare |
$14.57
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$18.22
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$14.57
|
| Rate for Payer: Healthfirst Medicare Advantage |
$14.57
|
| Rate for Payer: Healthfirst QHP |
$14.57
|
| Rate for Payer: Humana Medicare |
$14.86
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$14.57
|
| Rate for Payer: United Healthcare Commercial |
$18.46
|
| Rate for Payer: United Healthcare Medicare Advantage |
$14.57
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$14.57
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$11.66
|
| Rate for Payer: Wellcare Medicare |
$13.11
|
|
|
AMNIHOOK
|
Facility
|
OP
|
$4.02
|
|
| Hospital Charge Code |
64903005
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$1.41 |
| Max. Negotiated Rate |
$3.22 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2.21
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.01
|
| Rate for Payer: Aetna Government |
$2.01
|
| 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 |
$2.73
|
| Rate for Payer: Group Health Inc Commercial |
$2.01
|
| Rate for Payer: Group Health Inc Medicare |
$1.41
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.01
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2.01
|
|
|
AMNIOCENTESIS DX
|
Facility
|
IP
|
$1,933.73
|
|
|
Service Code
|
HCPCS 59000
|
| Hospital Charge Code |
30301257
|
|
Hospital Revenue Code
|
510
|
| Rate for Payer: Cash Price |
$929.66
|
|
|
AMNIOCENTESIS DX
|
Facility
|
OP
|
$1,933.73
|
|
|
Service Code
|
HCPCS 59000
|
| Hospital Charge Code |
30301257
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$222.00 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,412.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$929.66
|
| Rate for Payer: Aetna Government |
$929.66
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$650.76
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$650.76
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$650.76
|
| Rate for Payer: Brighton Health Commercial |
$233.00
|
| Rate for Payer: Cash Price |
$929.66
|
| Rate for Payer: Cash Price |
$929.66
|
| Rate for Payer: Cash Price |
$929.66
|
| Rate for Payer: Cash Price |
$929.66
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$929.66
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2,915.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,477.75
|
| Rate for Payer: Elderplan Medicare Advantage |
$929.66
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$790.21
|
| Rate for Payer: Fidelis Essential Plan QHP |
$827.40
|
| Rate for Payer: Fidelis Medicare Advantage |
$929.66
|
| Rate for Payer: Fidelis Qualified Health Plan |
$827.40
|
| 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 |
$966.86
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$929.66
|
| Rate for Payer: Healthfirst Medicare Advantage |
$790.21
|
| Rate for Payer: Healthfirst QHP |
$929.66
|
| Rate for Payer: Humana Medicare |
$948.25
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$929.66
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$929.66
|
| Rate for Payer: United Healthcare Commercial |
$222.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$929.66
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$929.66
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$743.73
|
| Rate for Payer: Wellcare Medicare |
$883.18
|
|
|
AMNT PAIN NOTED NON PRSNT
|
Facility
|
OP
|
$10.00
|
|
|
Service Code
|
HCPCS 1126F
|
| Hospital Charge Code |
30305815
|
|
Hospital Revenue Code
|
969
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$5.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.01
|
| Rate for Payer: Aetna Government |
$0.01
|
| Rate for Payer: Brighton Health Commercial |
$7.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2,915.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,477.75
|
| Rate for Payer: Group Health Inc Commercial |
$5.00
|
| Rate for Payer: Group Health Inc Medicare |
$3.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$5.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$5.00
|
|
|
AMNT PAIN NOTED PAIN PRESNT
|
Facility
|
OP
|
$10.00
|
|
|
Service Code
|
HCPCS 1125F
|
| Hospital Charge Code |
30305814
|
|
Hospital Revenue Code
|
969
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$5.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.01
|
| Rate for Payer: Aetna Government |
$0.01
|
| Rate for Payer: Brighton Health Commercial |
$7.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2,915.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,477.75
|
| Rate for Payer: Group Health Inc Commercial |
$5.00
|
| Rate for Payer: Group Health Inc Medicare |
$3.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$5.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$5.00
|
|
|
AMO LENS 13.0 13MMX6MM
|
Facility
|
OP
|
$350.00
|
|
|
Service Code
|
HCPCS C1840
|
| Hospital Charge Code |
40209383
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$122.50 |
| Max. Negotiated Rate |
$648.95 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$192.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$648.95
|
| Rate for Payer: Aetna Government |
$648.95
|
| Rate for Payer: Brighton Health Commercial |
$210.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$280.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$238.00
|
| Rate for Payer: EmblemHealth Commercial |
$175.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$367.50
|
| Rate for Payer: Group Health Inc Commercial |
$175.00
|
| Rate for Payer: Group Health Inc Medicare |
$122.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$175.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$175.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$227.50
|
|
|
AMOXICILLIN 125 MG/5ML PO SUSR [453]
|
Facility
|
OP
|
$0.04
|
|
|
Service Code
|
NDC 00143988880
|
| Hospital Charge Code |
00143988880
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.02
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.02
|
| Rate for Payer: Aetna Government |
$0.02
|
| Rate for Payer: Brighton Health Commercial |
$0.03
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.03
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.03
|
| Rate for Payer: Group Health Inc Commercial |
$0.02
|
| Rate for Payer: Group Health Inc Medicare |
$0.01
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.02
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.02
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.03
|
|
|
AMOXICILLIN 125 MG/5ML PO SUSR [453]
|
Facility
|
OP
|
$0.03
|
|
|
Service Code
|
NDC 00781603955
|
| Hospital Charge Code |
00781603955
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.02 |
| 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 |
$0.02
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.02
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.02
|
| 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 |
$0.02
|
|
