|
AMPHOTERICIN B LIPOSOMAL INJ
|
Facility
|
IP
|
$62.01
|
|
|
Service Code
|
HCPCS J0289
|
| Hospital Charge Code |
41654693
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$31.00 |
| Max. Negotiated Rate |
$31.00 |
| Rate for Payer: Cash Price |
$26.66
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$31.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$31.00
|
|
|
AMPHOTERICIN B LIPOSOMAL INJ
|
Facility
|
IP
|
$62.01
|
|
|
Service Code
|
HCPCS J0289
|
| Hospital Charge Code |
41644693
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$31.00 |
| Max. Negotiated Rate |
$31.00 |
| Rate for Payer: Cash Price |
$26.66
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$31.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$31.00
|
|
|
AMPHOTERICIN B LIPOSOMAL INJ
|
Facility
|
OP
|
$62.01
|
|
|
Service Code
|
HCPCS J0289
|
| Hospital Charge Code |
41654693
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.66 |
| Max. Negotiated Rate |
$40.31 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$34.11
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$26.66
|
| Rate for Payer: Aetna Government |
$26.66
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$18.66
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$18.66
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$18.66
|
| Rate for Payer: Brighton Health Commercial |
$37.21
|
| Rate for Payer: Cash Price |
$26.66
|
| Rate for Payer: Cash Price |
$26.66
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$26.66
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$31.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$35.66
|
| Rate for Payer: Elderplan Medicare Advantage |
$26.66
|
| Rate for Payer: EmblemHealth Commercial |
$26.66
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$26.66
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$26.66
|
| Rate for Payer: Fidelis Essential Plan QHP |
$27.99
|
| Rate for Payer: Fidelis Medicare Advantage |
$26.66
|
| Rate for Payer: Fidelis Qualified Health Plan |
$27.99
|
| Rate for Payer: Group Health Inc Commercial |
$26.66
|
| Rate for Payer: Group Health Inc Medicare |
$26.66
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$31.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$31.00
|
| Rate for Payer: Healthfirst Medicare Advantage |
$22.66
|
| Rate for Payer: Healthfirst QHP |
$26.66
|
| Rate for Payer: Humana Medicare |
$27.19
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$26.66
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$29.34
|
| Rate for Payer: SOMOS Essential |
$29.34
|
| Rate for Payer: United Healthcare Commercial |
$24.52
|
| Rate for Payer: United Healthcare Medicare Advantage |
$26.66
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$40.31
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$21.33
|
| Rate for Payer: Wellcare Medicare |
$25.33
|
|
|
AMPHOTERICIN B LIPOSOMAL INJ
|
Facility
|
OP
|
$62.01
|
|
|
Service Code
|
HCPCS J0289
|
| Hospital Charge Code |
41644693
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.66 |
| Max. Negotiated Rate |
$40.31 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$34.11
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$26.66
|
| Rate for Payer: Aetna Government |
$26.66
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$18.66
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$18.66
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$18.66
|
| Rate for Payer: Brighton Health Commercial |
$37.21
|
| Rate for Payer: Cash Price |
$26.66
|
| Rate for Payer: Cash Price |
$26.66
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$26.66
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$31.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$35.66
|
| Rate for Payer: Elderplan Medicare Advantage |
$26.66
|
| Rate for Payer: EmblemHealth Commercial |
$26.66
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$26.66
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$26.66
|
| Rate for Payer: Fidelis Essential Plan QHP |
$27.99
|
| Rate for Payer: Fidelis Medicare Advantage |
$26.66
|
| Rate for Payer: Fidelis Qualified Health Plan |
$27.99
|
| Rate for Payer: Group Health Inc Commercial |
$26.66
|
| Rate for Payer: Group Health Inc Medicare |
$26.66
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$31.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$31.00
|
| Rate for Payer: Healthfirst Medicare Advantage |
$22.66
|
| Rate for Payer: Healthfirst QHP |
$26.66
|
| Rate for Payer: Humana Medicare |
$27.19
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$26.66
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$29.34
|
| Rate for Payer: SOMOS Essential |
$29.34
|
| Rate for Payer: United Healthcare Commercial |
$24.52
|
| Rate for Payer: United Healthcare Medicare Advantage |
$26.66
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$40.31
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$21.33
|
| Rate for Payer: Wellcare Medicare |
$25.33
|
|
|
AMPHOTERICIN B LIPOSOME 0.5MG/ML
|
Facility
|
OP
|
$8.50
|
|
|
Service Code
|
HCPCS J0289
|
| Hospital Charge Code |
41650329
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.25 |
| Max. Negotiated Rate |
$29.34 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$4.68
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$26.66
|
| Rate for Payer: Aetna Government |
$26.66
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$18.66
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$18.66
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$18.66
|
| Rate for Payer: Brighton Health Commercial |
$5.10
|
| Rate for Payer: Cash Price |
$26.66
|
| Rate for Payer: Cash Price |
$26.66
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$26.66
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$4.25
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$4.89
|
| Rate for Payer: Elderplan Medicare Advantage |
$26.66
|
| Rate for Payer: EmblemHealth Commercial |
$26.66
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$26.66
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$26.66
|
| Rate for Payer: Fidelis Essential Plan QHP |
$27.99
|
| Rate for Payer: Fidelis Medicare Advantage |
$26.66
|
| Rate for Payer: Fidelis Qualified Health Plan |
$27.99
|
| Rate for Payer: Group Health Inc Commercial |
$26.66
|
| Rate for Payer: Group Health Inc Medicare |
$26.66
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4.25
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4.25
|
| Rate for Payer: Healthfirst Medicare Advantage |
$22.66
|
| Rate for Payer: Healthfirst QHP |
$26.66
|
| Rate for Payer: Humana Medicare |
$27.19
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$26.66
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$29.34
|
| Rate for Payer: SOMOS Essential |
$29.34
|
| Rate for Payer: United Healthcare Commercial |
$24.52
|
| Rate for Payer: United Healthcare Medicare Advantage |
$26.66
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$5.52
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$21.33
|
| Rate for Payer: Wellcare Medicare |
$25.33
|
|
|
AMPHOTERICIN B LIPOSOME 0.5MG/ML
|
Facility
|
IP
|
$8.50
|
|
|
Service Code
|
HCPCS J0289
|
| Hospital Charge Code |
41640329
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.25 |
| Max. Negotiated Rate |
$4.25 |
| Rate for Payer: Cash Price |
$26.66
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4.25
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4.25
|
|
|
AMPHOTERICIN B LIPOSOME 0.5MG/ML
|
Facility
|
OP
|
$8.50
|
|
|
Service Code
|
HCPCS J0289
|
| Hospital Charge Code |
41640329
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.25 |
| Max. Negotiated Rate |
$29.34 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$4.68
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$26.66
|
| Rate for Payer: Aetna Government |
$26.66
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$18.66
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$18.66
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$18.66
|
| Rate for Payer: Brighton Health Commercial |
$5.10
|
| Rate for Payer: Cash Price |
$26.66
|
| Rate for Payer: Cash Price |
$26.66
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$26.66
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$4.25
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$4.89
|
| Rate for Payer: Elderplan Medicare Advantage |
$26.66
|
| Rate for Payer: EmblemHealth Commercial |
$26.66
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$26.66
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$26.66
|
| Rate for Payer: Fidelis Essential Plan QHP |
$27.99
|
| Rate for Payer: Fidelis Medicare Advantage |
$26.66
|
| Rate for Payer: Fidelis Qualified Health Plan |
$27.99
|
| Rate for Payer: Group Health Inc Commercial |
$26.66
|
| Rate for Payer: Group Health Inc Medicare |
$26.66
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4.25
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4.25
|
| Rate for Payer: Healthfirst Medicare Advantage |
$22.66
|
| Rate for Payer: Healthfirst QHP |
$26.66
|
| Rate for Payer: Humana Medicare |
$27.19
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$26.66
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$29.34
|
| Rate for Payer: SOMOS Essential |
$29.34
|
| Rate for Payer: United Healthcare Commercial |
$24.52
|
| Rate for Payer: United Healthcare Medicare Advantage |
$26.66
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$5.52
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$21.33
|
| Rate for Payer: Wellcare Medicare |
$25.33
|
|
|
AMPHOTERICIN B LIPOSOME 0.5MG/ML
|
Facility
|
IP
|
$8.50
|
|
|
Service Code
|
HCPCS J0289
|
| Hospital Charge Code |
41650329
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.25 |
| Max. Negotiated Rate |
$4.25 |
| Rate for Payer: Cash Price |
$26.66
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4.25
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4.25
|
|
|
AMPHOTERICIN B LIPOSOME 50 MG IV SUSR [21900]
|
Facility
|
OP
|
$370.85
|
|
|
Service Code
|
HCPCS J0289
|
| Hospital Charge Code |
00469305130
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$21.33 |
| Max. Negotiated Rate |
$241.05 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$203.97
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$26.66
|
| Rate for Payer: Aetna Government |
$26.66
|
| Rate for Payer: Brighton Health Commercial |
$222.51
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$26.66
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$185.42
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$213.24
|
| Rate for Payer: Elderplan Medicare Advantage |
$26.66
|
| Rate for Payer: EmblemHealth Commercial |
$185.42
|
| Rate for Payer: Fidelis Medicare Advantage |
$26.66
|
| Rate for Payer: Group Health Inc Commercial |
$26.66
|
| Rate for Payer: Group Health Inc Medicare |
$26.66
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$185.42
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$185.42
|
| Rate for Payer: Healthfirst Medicare Advantage |
$22.66
|
| Rate for Payer: Healthfirst QHP |
$26.66
|
| Rate for Payer: Humana Medicare |
$27.19
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$26.66
|
| Rate for Payer: United Healthcare Medicare Advantage |
$26.66
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$241.05
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$21.33
|
|
|
AMPHOTERICIN B LIPOSOME 50 MG IV SUSR [21900]
|
Facility
|
OP
|
$305.70
|
|
|
Service Code
|
HCPCS J0289
|
| Hospital Charge Code |
55150036501
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$21.33 |
| Max. Negotiated Rate |
$198.70 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$168.14
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$26.66
|
| Rate for Payer: Aetna Government |
$26.66
|
| Rate for Payer: Brighton Health Commercial |
$183.42
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$26.66
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$152.85
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$175.78
|
| Rate for Payer: Elderplan Medicare Advantage |
$26.66
|
| Rate for Payer: EmblemHealth Commercial |
$152.85
|
| Rate for Payer: Fidelis Medicare Advantage |
$26.66
|
| Rate for Payer: Group Health Inc Commercial |
$26.66
|
| Rate for Payer: Group Health Inc Medicare |
$26.66
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$152.85
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$152.85
|
| Rate for Payer: Healthfirst Medicare Advantage |
$22.66
|
| Rate for Payer: Healthfirst QHP |
$26.66
|
| Rate for Payer: Humana Medicare |
$27.19
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$26.66
|
| Rate for Payer: United Healthcare Medicare Advantage |
$26.66
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$198.70
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$21.33
|
|
|
AMPHOTERICIN B LIPOSOME 50 MG IV SUSR [21900]
|
Facility
|
IP
|
$305.70
|
|
|
Service Code
|
HCPCS J0289
|
| Hospital Charge Code |
55150036501
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$152.85 |
| Max. Negotiated Rate |
$152.85 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$152.85
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$152.85
|
|
|
AMPHOTERICIN B LIPOSOME 50 MG IV SUSR [21900]
|
Facility
|
IP
|
$305.69
|
|
|
Service Code
|
HCPCS J0289
|
| Hospital Charge Code |
62756023301
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$152.84 |
| Max. Negotiated Rate |
$152.84 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$152.84
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$152.84
|
|
|
AMPHOTERICIN B LIPOSOME 50 MG IV SUSR [21900]
|
Facility
|
OP
|
$305.69
|
|
|
Service Code
|
HCPCS J0289
|
| Hospital Charge Code |
62756023301
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$21.33 |
| Max. Negotiated Rate |
$198.70 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$168.13
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$26.66
|
| Rate for Payer: Aetna Government |
$26.66
|
| Rate for Payer: Brighton Health Commercial |
$183.41
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$26.66
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$152.84
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$175.77
|
| Rate for Payer: Elderplan Medicare Advantage |
$26.66
|
| Rate for Payer: EmblemHealth Commercial |
$152.84
|
| Rate for Payer: Fidelis Medicare Advantage |
$26.66
|
| Rate for Payer: Group Health Inc Commercial |
$26.66
|
| Rate for Payer: Group Health Inc Medicare |
$26.66
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$152.84
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$152.84
|
| Rate for Payer: Healthfirst Medicare Advantage |
$22.66
|
| Rate for Payer: Healthfirst QHP |
$26.66
|
| Rate for Payer: Humana Medicare |
$27.19
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$26.66
|
| Rate for Payer: United Healthcare Medicare Advantage |
$26.66
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$198.70
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$21.33
|
|
|
AMPHOTERICIN B LIPOSOME 50 MG IV SUSR [21900]
|
Facility
|
IP
|
$370.85
|
|
|
Service Code
|
HCPCS J0289
|
| Hospital Charge Code |
00469305130
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$185.42 |
| Max. Negotiated Rate |
$185.42 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$185.42
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$185.42
|
|
|
AMPICILLIN 1000 MG INJ
|
Facility
|
IP
|
$2.74
|
|
|
Service Code
|
HCPCS J0290
|
| Hospital Charge Code |
41654180
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.37 |
| Max. Negotiated Rate |
$1.37 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.37
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.37
|
|
|
AMPICILLIN 1000 MG INJ
|
Facility
|
OP
|
$2.74
|
|
|
Service Code
|
HCPCS J0290
|
| Hospital Charge Code |
41644180
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.81 |
| Max. Negotiated Rate |
$1.78 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.51
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.81
|
| Rate for Payer: Aetna Government |
$0.81
|
| Rate for Payer: Brighton Health Commercial |
$1.64
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.37
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.58
|
| Rate for Payer: Group Health Inc Commercial |
$1.37
|
| Rate for Payer: Group Health Inc Medicare |
$0.96
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.37
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.37
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$1.06
|
| Rate for Payer: SOMOS Essential |
$1.06
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.78
|
|
|
AMPICILLIN 1000 MG INJ
|
Facility
|
IP
|
$2.74
|
|
|
Service Code
|
HCPCS J0290
|
| Hospital Charge Code |
41644180
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.37 |
| Max. Negotiated Rate |
$1.37 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.37
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.37
|
|
|
AMPICILLIN 1000 MG INJ
|
Facility
|
OP
|
$2.74
|
|
|
Service Code
|
HCPCS J0290
|
| Hospital Charge Code |
41654180
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.81 |
| Max. Negotiated Rate |
$1.78 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.51
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.81
|
| Rate for Payer: Aetna Government |
$0.81
|
| Rate for Payer: Brighton Health Commercial |
$1.64
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.37
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.58
|
| Rate for Payer: Group Health Inc Commercial |
$1.37
|
| Rate for Payer: Group Health Inc Medicare |
$0.96
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.37
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.37
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$1.06
|
| Rate for Payer: SOMOS Essential |
$1.06
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.78
|
|
|
AMPICILLIN 125 MG INJ
|
Facility
|
IP
|
$32.55
|
|
|
Service Code
|
HCPCS J0290
|
| Hospital Charge Code |
41654267
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.28 |
| Max. Negotiated Rate |
$16.28 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$16.28
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$16.28
|
|
|
AMPICILLIN 125 MG INJ
|
Facility
|
OP
|
$32.55
|
|
|
Service Code
|
HCPCS J0290
|
| Hospital Charge Code |
41644267
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.81 |
| Max. Negotiated Rate |
$21.16 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$17.90
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.81
|
| Rate for Payer: Aetna Government |
$0.81
|
| Rate for Payer: Brighton Health Commercial |
$19.53
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$16.28
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$18.72
|
| Rate for Payer: Group Health Inc Commercial |
$16.28
|
| Rate for Payer: Group Health Inc Medicare |
$11.39
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$16.28
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$16.28
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$1.06
|
| Rate for Payer: SOMOS Essential |
$1.06
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$21.16
|
|
|
AMPICILLIN 125 MG INJ
|
Facility
|
OP
|
$32.55
|
|
|
Service Code
|
HCPCS J0290
|
| Hospital Charge Code |
41654267
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.81 |
| Max. Negotiated Rate |
$21.16 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$17.90
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.81
|
| Rate for Payer: Aetna Government |
$0.81
|
| Rate for Payer: Brighton Health Commercial |
$19.53
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$16.28
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$18.72
|
| Rate for Payer: Group Health Inc Commercial |
$16.28
|
| Rate for Payer: Group Health Inc Medicare |
$11.39
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$16.28
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$16.28
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$1.06
|
| Rate for Payer: SOMOS Essential |
$1.06
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$21.16
|
|
|
AMPICILLIN 125 MG INJ
|
Facility
|
IP
|
$32.55
|
|
|
Service Code
|
HCPCS J0290
|
| Hospital Charge Code |
41644267
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.28 |
| Max. Negotiated Rate |
$16.28 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$16.28
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$16.28
|
|
|
AMPICILLIN 2000 MG INJ
|
Facility
|
IP
|
$1.74
|
|
|
Service Code
|
HCPCS J0290
|
| Hospital Charge Code |
41654181
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.87 |
| Max. Negotiated Rate |
$0.87 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.87
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.87
|
|
|
AMPICILLIN 2000 MG INJ
|
Facility
|
IP
|
$1.74
|
|
|
Service Code
|
HCPCS J0290
|
| Hospital Charge Code |
41644181
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.87 |
| Max. Negotiated Rate |
$0.87 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.87
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.87
|
|
|
AMPICILLIN 2000 MG INJ
|
Facility
|
OP
|
$1.74
|
|
|
Service Code
|
HCPCS J0290
|
| Hospital Charge Code |
41644181
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$1.13 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.96
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.81
|
| Rate for Payer: Aetna Government |
$0.81
|
| Rate for Payer: Brighton Health Commercial |
$1.04
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.87
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.00
|
| 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: SOMOS CHP/HARP/Medicaid |
$1.06
|
| Rate for Payer: SOMOS Essential |
$1.06
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.13
|
|
