|
POLY-VITA PO SOLN
|
Facility
|
OP
|
$0.20
|
|
|
Service Code
|
NDC 0087040203
|
| Hospital Charge Code |
0087040203
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.11
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.10
|
| Rate for Payer: Aetna Government |
$0.10
|
| Rate for Payer: Brighton Health Commercial |
$0.15
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.16
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.13
|
| Rate for Payer: EmblemHealth Commercial |
$0.10
|
| Rate for Payer: Group Health Inc Commercial |
$0.10
|
| Rate for Payer: Group Health Inc Medicare |
$0.07
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.10
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.10
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.13
|
|
|
PORACTANT ALFA 120 MG/1.5ML INTRATRACHEA SUSP
|
Facility
|
OP
|
$456.79
|
|
|
Service Code
|
NDC 1012251001
|
| Hospital Charge Code |
1012251001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$159.88 |
| Max. Negotiated Rate |
$365.43 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$251.23
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$228.39
|
| Rate for Payer: Aetna Government |
$228.39
|
| Rate for Payer: Brighton Health Commercial |
$342.59
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$365.43
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$310.62
|
| Rate for Payer: EmblemHealth Commercial |
$228.39
|
| Rate for Payer: Group Health Inc Commercial |
$228.39
|
| Rate for Payer: Group Health Inc Medicare |
$159.88
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$228.39
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$228.39
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$296.91
|
|
|
PORACTANT ALFA 120 MG/1.5ML INTRATRACHEA SUSP
|
Facility
|
IP
|
$456.79
|
|
|
Service Code
|
NDC 1012251001
|
| Hospital Charge Code |
1012251001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$228.39 |
| Max. Negotiated Rate |
$228.39 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$228.39
|
|
|
PORACTANT ALFA 240 MG/3ML INTRATRACHEA SUSP
|
Facility
|
OP
|
$450.36
|
|
|
Service Code
|
NDC 1012251003
|
| Hospital Charge Code |
1012251003
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$157.63 |
| Max. Negotiated Rate |
$360.29 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$247.70
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$225.18
|
| Rate for Payer: Aetna Government |
$225.18
|
| Rate for Payer: Brighton Health Commercial |
$337.77
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$360.29
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$306.25
|
| Rate for Payer: EmblemHealth Commercial |
$225.18
|
| Rate for Payer: Group Health Inc Commercial |
$225.18
|
| Rate for Payer: Group Health Inc Medicare |
$157.63
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$225.18
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$225.18
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$292.74
|
|
|
PORACTANT ALFA 240 MG/3ML INTRATRACHEA SUSP
|
Facility
|
IP
|
$450.36
|
|
|
Service Code
|
NDC 1012251003
|
| Hospital Charge Code |
1012251003
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$225.18 |
| Max. Negotiated Rate |
$225.18 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$225.18
|
|
|
Post-operative, post-traumatic, other device infections
|
Facility
|
IP
|
$43,339.48
|
|
|
Service Code
|
APR-DRG 7211
|
| Min. Negotiated Rate |
$7,328.00 |
| Max. Negotiated Rate |
$43,339.48 |
| Rate for Payer: Affinity Essential Plan 1&2 |
$43,339.48
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$43,339.48
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$19,261.99
|
| Rate for Payer: Amida Care Medicaid |
$19,261.99
|
| Rate for Payer: EmblemHealth Essential Plan 1&2 |
$43,339.48
|
| Rate for Payer: EmblemHealth Essential Plan 3&4 |
$19,261.99
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$19,261.99
|
| Rate for Payer: Fidelis Qualified Health Plan |
$23,114.39
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$19,261.99
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$19,261.99
|
| Rate for Payer: Healthfirst Commercial |
$12,655.00
|
| Rate for Payer: Healthfirst Essential Plan |
$43,339.48
|
| Rate for Payer: Healthfirst QHP |
$7,328.00
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$19,261.99
|
| Rate for Payer: SOMOS Essential |
$43,339.48
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$43,339.48
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$43,339.48
|
| Rate for Payer: United Healthcare Medicaid |
$19,261.99
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$19,261.99
|
|
|
Post-operative, post-traumatic, other device infections
|
Facility
|
IP
|
$57,194.89
|
|
|
Service Code
|
APR-DRG 7213
|
| Min. Negotiated Rate |
$13,897.00 |
| Max. Negotiated Rate |
$57,194.89 |
| Rate for Payer: Affinity Essential Plan 1&2 |
$57,194.89
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$57,194.89
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$25,419.95
|
| Rate for Payer: Amida Care Medicaid |
$25,419.95
|
| Rate for Payer: EmblemHealth Essential Plan 1&2 |
$57,194.89
|
| Rate for Payer: EmblemHealth Essential Plan 3&4 |
$25,419.95
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$25,419.95
|
| Rate for Payer: Fidelis Qualified Health Plan |
$30,503.94
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$25,419.95
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$25,419.95
|
| Rate for Payer: Healthfirst Commercial |
$24,962.00
|
| Rate for Payer: Healthfirst Essential Plan |
$57,194.89
|
| Rate for Payer: Healthfirst QHP |
$13,897.00
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$25,419.95
|
| Rate for Payer: SOMOS Essential |
$57,194.89
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$57,194.89
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$57,194.89
|
| Rate for Payer: United Healthcare Medicaid |
$25,419.95
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$25,419.95
|
|
|
Post-operative, post-traumatic, other device infections
|
Facility
|
IP
|
$81,806.78
|
|
|
Service Code
|
APR-DRG 7214
|
| Min. Negotiated Rate |
$26,851.00 |
| Max. Negotiated Rate |
$81,806.78 |
| Rate for Payer: Affinity Essential Plan 1&2 |
$81,806.78
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$81,806.78
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$36,358.57
|
| Rate for Payer: Amida Care Medicaid |
$36,358.57
|
| Rate for Payer: EmblemHealth Essential Plan 1&2 |
$81,806.78
|
| Rate for Payer: EmblemHealth Essential Plan 3&4 |
$36,358.57
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$36,358.57
|
| Rate for Payer: Fidelis Qualified Health Plan |
$43,630.28
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$36,358.57
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$36,358.57
|
| Rate for Payer: Healthfirst Commercial |
$46,973.00
|
| Rate for Payer: Healthfirst Essential Plan |
$81,806.78
|
| Rate for Payer: Healthfirst QHP |
$26,851.00
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$36,358.57
|
| Rate for Payer: SOMOS Essential |
$81,806.78
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$81,806.78
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$81,806.78
|
| Rate for Payer: United Healthcare Medicaid |
$36,358.57
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$36,358.57
|
|
|
Post-operative, post-traumatic, other device infections
|
Facility
|
IP
|
$46,904.44
|
|
|
Service Code
|
APR-DRG 7212
|
| Min. Negotiated Rate |
$9,432.00 |
| Max. Negotiated Rate |
$46,904.44 |
| Rate for Payer: Affinity Essential Plan 1&2 |
$46,904.44
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$46,904.44
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$20,846.42
|
| Rate for Payer: Amida Care Medicaid |
$20,846.42
|
| Rate for Payer: EmblemHealth Essential Plan 1&2 |
$46,904.44
|
| Rate for Payer: EmblemHealth Essential Plan 3&4 |
$20,846.42
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$20,846.42
|
| Rate for Payer: Fidelis Qualified Health Plan |
$25,015.70
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$20,846.42
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$20,846.42
|
| Rate for Payer: Healthfirst Commercial |
$15,986.00
|
| Rate for Payer: Healthfirst Essential Plan |
$46,904.44
|
| Rate for Payer: Healthfirst QHP |
$9,432.00
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$20,846.42
|
| Rate for Payer: SOMOS Essential |
$46,904.44
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$46,904.44
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$46,904.44
|
| Rate for Payer: United Healthcare Medicaid |
$20,846.42
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$20,846.42
|
|
|
POST-OPERATIVE, POST-TRAUMATIC, OTHER DEVICE INFECTIONS AND COMPLICATIONS
|
Facility
|
OP
|
$248.36
|
|
|
Service Code
|
EAPG 00806
|
| Min. Negotiated Rate |
$180.52 |
| Max. Negotiated Rate |
$248.36 |
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$180.52
|
| Rate for Payer: Healthfirst Commercial |
$248.36
|
|
|
Post-op, post-trauma, other device infections w O.R. procedure
|
Facility
|
IP
|
$59,884.00
|
|
|
Service Code
|
APR-DRG 7112
|
| Min. Negotiated Rate |
$19,465.00 |
| Max. Negotiated Rate |
$59,884.00 |
| Rate for Payer: Affinity Essential Plan 1&2 |
$59,884.00
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$59,884.00
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$26,615.11
|
| Rate for Payer: Amida Care Medicaid |
$26,615.11
|
| Rate for Payer: EmblemHealth Essential Plan 1&2 |
$59,884.00
|
| Rate for Payer: EmblemHealth Essential Plan 3&4 |
$26,615.11
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$26,615.11
|
| Rate for Payer: Fidelis Qualified Health Plan |
$31,938.13
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$26,615.11
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$26,615.11
|
| Rate for Payer: Healthfirst Commercial |
$32,819.00
|
| Rate for Payer: Healthfirst Essential Plan |
$59,884.00
|
| Rate for Payer: Healthfirst QHP |
$19,465.00
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$26,615.11
|
| Rate for Payer: SOMOS Essential |
$59,884.00
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$59,884.00
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$59,884.00
|
| Rate for Payer: United Healthcare Medicaid |
$26,615.11
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$26,615.11
|
|
|
Post-op, post-trauma, other device infections w O.R. procedure
|
Facility
|
IP
|
$82,578.87
|
|
|
Service Code
|
APR-DRG 7113
|
| Min. Negotiated Rate |
$33,692.00 |
| Max. Negotiated Rate |
$82,578.87 |
| Rate for Payer: Affinity Essential Plan 1&2 |
$82,578.87
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$82,578.87
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$36,701.72
|
| Rate for Payer: Amida Care Medicaid |
$36,701.72
|
| Rate for Payer: EmblemHealth Essential Plan 1&2 |
$82,578.87
|
| Rate for Payer: EmblemHealth Essential Plan 3&4 |
$36,701.72
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$36,701.72
|
| Rate for Payer: Fidelis Qualified Health Plan |
$44,042.06
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$36,701.72
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$36,701.72
|
| Rate for Payer: Healthfirst Commercial |
$57,459.00
|
| Rate for Payer: Healthfirst Essential Plan |
$82,578.87
|
| Rate for Payer: Healthfirst QHP |
$33,692.00
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$36,701.72
|
| Rate for Payer: SOMOS Essential |
$82,578.87
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$82,578.87
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$82,578.87
|
| Rate for Payer: United Healthcare Medicaid |
$36,701.72
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$36,701.72
|
|
|
Post-op, post-trauma, other device infections w O.R. procedure
|
Facility
|
IP
|
$138,172.84
|
|
|
Service Code
|
APR-DRG 7114
|
| Min. Negotiated Rate |
$61,410.15 |
| Max. Negotiated Rate |
$138,172.84 |
| Rate for Payer: Affinity Essential Plan 1&2 |
$138,172.84
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$138,172.84
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$61,410.15
|
| Rate for Payer: Amida Care Medicaid |
$61,410.15
|
| Rate for Payer: EmblemHealth Essential Plan 1&2 |
$138,172.84
|
| Rate for Payer: EmblemHealth Essential Plan 3&4 |
$61,410.15
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$61,410.15
|
| Rate for Payer: Fidelis Qualified Health Plan |
$73,692.18
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$61,410.15
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$61,410.15
|
| Rate for Payer: Healthfirst Commercial |
$118,117.00
|
| Rate for Payer: Healthfirst Essential Plan |
$138,172.84
|
| Rate for Payer: Healthfirst QHP |
$72,861.00
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$61,410.15
|
| Rate for Payer: SOMOS Essential |
$138,172.84
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$138,172.84
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$138,172.84
|
| Rate for Payer: United Healthcare Medicaid |
$61,410.15
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$61,410.15
|
|
|
Post-op, post-trauma, other device infections w O.R. procedure
|
Facility
|
IP
|
$52,388.24
|
|
|
Service Code
|
APR-DRG 7111
|
| Min. Negotiated Rate |
$13,367.00 |
| Max. Negotiated Rate |
$52,388.24 |
| Rate for Payer: Affinity Essential Plan 1&2 |
$52,388.24
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$52,388.24
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$23,283.66
|
| Rate for Payer: Amida Care Medicaid |
$23,283.66
|
| Rate for Payer: EmblemHealth Essential Plan 1&2 |
$52,388.24
|
| Rate for Payer: EmblemHealth Essential Plan 3&4 |
$23,283.66
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$23,283.66
|
| Rate for Payer: Fidelis Qualified Health Plan |
$27,940.39
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$23,283.66
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$23,283.66
|
| Rate for Payer: Healthfirst Commercial |
$23,671.00
|
| Rate for Payer: Healthfirst Essential Plan |
$52,388.24
|
| Rate for Payer: Healthfirst QHP |
$13,367.00
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$23,283.66
|
| Rate for Payer: SOMOS Essential |
$52,388.24
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$52,388.24
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$52,388.24
|
| Rate for Payer: United Healthcare Medicaid |
$23,283.66
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$23,283.66
|
|
|
POSTPARTUM AND POST ABORTION DIAGNOSES
|
Facility
|
OP
|
$229.81
|
|
|
Service Code
|
EAPG 00761
|
| Min. Negotiated Rate |
$166.63 |
| Max. Negotiated Rate |
$229.81 |
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$166.63
|
| Rate for Payer: Healthfirst Commercial |
$229.81
|
|
|
Postpartum & post abortion diagnoses w/o procedure
|
Facility
|
IP
|
$8,488.00
|
|
|
Service Code
|
APR-DRG 5611
|
| Min. Negotiated Rate |
$3,351.52 |
| Max. Negotiated Rate |
$8,488.00 |
| Rate for Payer: Affinity Essential Plan 1&2 |
$3,351.52
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$3,351.52
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$3,351.52
|
| Rate for Payer: Carelon Behavioral Health HARP/QHP |
$3,351.52
|
| Rate for Payer: EmblemHealth Essential Plan 1&2 |
$7,540.92
|
| Rate for Payer: EmblemHealth Essential Plan 3&4 |
$3,351.52
|
| Rate for Payer: Fidelis Qualified Health Plan |
$4,021.82
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$3,351.52
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$3,351.52
|
| Rate for Payer: Healthfirst Commercial |
$8,488.00
|
| Rate for Payer: Healthfirst Essential Plan |
$7,540.92
|
| Rate for Payer: Healthfirst QHP |
$6,099.77
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$3,351.52
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$7,540.92
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$7,540.92
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$3,351.52
|
| Rate for Payer: SOMOS Essential |
$7,540.92
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$7,540.92
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$7,540.92
|
| Rate for Payer: United Healthcare Medicaid |
$3,351.52
|
|
|
Postpartum & post abortion diagnoses w/o procedure
|
Facility
|
IP
|
$13,649.00
|
|
|
Service Code
|
APR-DRG 5613
|
| Min. Negotiated Rate |
$3,351.52 |
| Max. Negotiated Rate |
$13,649.00 |
| Rate for Payer: Affinity Essential Plan 1&2 |
$3,351.52
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$3,351.52
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$3,351.52
|
| Rate for Payer: Carelon Behavioral Health HARP/QHP |
$3,351.52
|
| Rate for Payer: EmblemHealth Essential Plan 1&2 |
$7,540.92
|
| Rate for Payer: EmblemHealth Essential Plan 3&4 |
$3,351.52
|
| Rate for Payer: Fidelis Qualified Health Plan |
$4,021.82
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$3,351.52
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$3,351.52
|
| Rate for Payer: Healthfirst Commercial |
$13,649.00
|
| Rate for Payer: Healthfirst Essential Plan |
$7,540.92
|
| Rate for Payer: Healthfirst QHP |
$6,099.77
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$3,351.52
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$7,540.92
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$7,540.92
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$3,351.52
|
| Rate for Payer: SOMOS Essential |
$7,540.92
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$7,540.92
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$7,540.92
|
| Rate for Payer: United Healthcare Medicaid |
$3,351.52
|
|
|
Postpartum & post abortion diagnoses w/o procedure
|
Facility
|
IP
|
$9,801.00
|
|
|
Service Code
|
APR-DRG 5612
|
| Min. Negotiated Rate |
$3,351.52 |
| Max. Negotiated Rate |
$9,801.00 |
| Rate for Payer: Affinity Essential Plan 1&2 |
$3,351.52
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$3,351.52
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$3,351.52
|
| Rate for Payer: Carelon Behavioral Health HARP/QHP |
$3,351.52
|
| Rate for Payer: EmblemHealth Essential Plan 1&2 |
$7,540.92
|
| Rate for Payer: EmblemHealth Essential Plan 3&4 |
$3,351.52
|
| Rate for Payer: Fidelis Qualified Health Plan |
$4,021.82
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$3,351.52
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$3,351.52
|
| Rate for Payer: Healthfirst Commercial |
$9,801.00
|
| Rate for Payer: Healthfirst Essential Plan |
$7,540.92
|
| Rate for Payer: Healthfirst QHP |
$6,099.77
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$3,351.52
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$7,540.92
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$7,540.92
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$3,351.52
|
| Rate for Payer: SOMOS Essential |
$7,540.92
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$7,540.92
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$7,540.92
|
| Rate for Payer: United Healthcare Medicaid |
$3,351.52
|
|
|
Postpartum & post abortion diagnoses w/o procedure
|
Facility
|
IP
|
$29,997.00
|
|
|
Service Code
|
APR-DRG 5614
|
| Min. Negotiated Rate |
$3,351.52 |
| Max. Negotiated Rate |
$29,997.00 |
| Rate for Payer: Affinity Essential Plan 1&2 |
$3,351.52
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$3,351.52
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$3,351.52
|
| Rate for Payer: Carelon Behavioral Health HARP/QHP |
$3,351.52
|
| Rate for Payer: EmblemHealth Essential Plan 1&2 |
$7,540.92
|
| Rate for Payer: EmblemHealth Essential Plan 3&4 |
$3,351.52
|
| Rate for Payer: Fidelis Qualified Health Plan |
$4,021.82
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$3,351.52
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$3,351.52
|
| Rate for Payer: Healthfirst Commercial |
$29,997.00
|
| Rate for Payer: Healthfirst Essential Plan |
$7,540.92
|
| Rate for Payer: Healthfirst QHP |
$6,099.77
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$3,351.52
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$7,540.92
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$7,540.92
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$3,351.52
|
| Rate for Payer: SOMOS Essential |
$7,540.92
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$7,540.92
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$7,540.92
|
| Rate for Payer: United Healthcare Medicaid |
$3,351.52
|
|
|
POTASSIUM ACETATE 2 MEQ/ML IV SOLN
|
Facility
|
OP
|
$0.21
|
|
|
Service Code
|
NDC 0409818301
|
| Hospital Charge Code |
0409818301
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.11
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.10
|
| Rate for Payer: Aetna Government |
$0.10
|
| Rate for Payer: Brighton Health Commercial |
$0.16
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.17
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.14
|
| Rate for Payer: EmblemHealth Commercial |
$0.10
|
| Rate for Payer: Group Health Inc Commercial |
$0.10
|
| Rate for Payer: Group Health Inc Medicare |
$0.07
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.10
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.10
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.13
|
|
|
POTASSIUM ACETATE 2 MEQ/ML IV SOLN
|
Facility
|
IP
|
$0.26
|
|
|
Service Code
|
NDC 0409329451
|
| Hospital Charge Code |
0409329451
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.13
|
|
|
POTASSIUM ACETATE 2 MEQ/ML IV SOLN
|
Facility
|
IP
|
$0.32
|
|
|
Service Code
|
NDC 5175420014
|
| Hospital Charge Code |
5175420014
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.16
|
|
|
POTASSIUM ACETATE 2 MEQ/ML IV SOLN
|
Facility
|
OP
|
$0.26
|
|
|
Service Code
|
NDC 0409329451
|
| Hospital Charge Code |
0409329451
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.14
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.13
|
| Rate for Payer: Aetna Government |
$0.13
|
| Rate for Payer: Brighton Health Commercial |
$0.19
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.20
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.17
|
| Rate for Payer: EmblemHealth Commercial |
$0.13
|
| 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
|
|
|
POTASSIUM ACETATE 2 MEQ/ML IV SOLN
|
Facility
|
OP
|
$0.21
|
|
|
Service Code
|
NDC 0409818311
|
| Hospital Charge Code |
0409818311
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.11
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.10
|
| Rate for Payer: Aetna Government |
$0.10
|
| Rate for Payer: Brighton Health Commercial |
$0.16
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.17
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.14
|
| Rate for Payer: EmblemHealth Commercial |
$0.10
|
| Rate for Payer: Group Health Inc Commercial |
$0.10
|
| Rate for Payer: Group Health Inc Medicare |
$0.07
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.10
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.10
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.13
|
|
|
POTASSIUM ACETATE 2 MEQ/ML IV SOLN
|
Facility
|
IP
|
$0.21
|
|
|
Service Code
|
NDC 0409818311
|
| Hospital Charge Code |
0409818311
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.10 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.10
|
|
