|
IMMUNE ADMIN O OR N, < 8 YRS
|
Facility
|
OP
|
$35.25
|
|
|
Service Code
|
HCPCS 90460
|
| Hospital Charge Code |
30301232
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$10.00 |
| Max. Negotiated Rate |
$250.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$19.39
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$10.00
|
| Rate for Payer: Aetna Government |
$10.00
|
| Rate for Payer: Brighton Health Commercial |
$26.44
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$28.20
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$23.97
|
| 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 |
$17.62
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$17.62
|
| Rate for Payer: United Healthcare Commercial |
$44.00
|
|
|
IMMUNE ADMIN ORAL/NASAL
|
Facility
|
OP
|
$183.15
|
|
|
Service Code
|
HCPCS 90473
|
| Hospital Charge Code |
30301228
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$8.66 |
| Max. Negotiated Rate |
$866.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$100.73
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$81.46
|
| Rate for Payer: Aetna Government |
$81.46
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$19.48
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$19.48
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$8.66
|
| Rate for Payer: Amida Care Medicaid |
$8.66
|
| Rate for Payer: Brighton Health Commercial |
$137.36
|
| Rate for Payer: Cash Price |
$81.46
|
| Rate for Payer: Cash Price |
$81.46
|
| Rate for Payer: Cash Price |
$81.46
|
| Rate for Payer: Cash Price |
$81.46
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$81.46
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$146.52
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$124.54
|
| Rate for Payer: Elderplan Medicare Advantage |
$81.46
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$866.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$8.66
|
| Rate for Payer: Fidelis Essential Plan QHP |
$8.66
|
| Rate for Payer: Fidelis Medicare Advantage |
$81.46
|
| Rate for Payer: Fidelis Qualified Health Plan |
$9.09
|
| 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 |
$8.66
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$81.46
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$8.66
|
| Rate for Payer: Healthfirst Essential Plan |
$19.48
|
| Rate for Payer: Healthfirst Medicare Advantage |
$69.24
|
| Rate for Payer: Healthfirst QHP |
$8.66
|
| Rate for Payer: Humana Medicare |
$83.09
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$81.46
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$8.66
|
| Rate for Payer: SOMOS Essential |
$8.66
|
| Rate for Payer: United Healthcare Commercial |
$44.00
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$19.48
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$9.53
|
| Rate for Payer: United Healthcare Medicaid |
$8.66
|
| Rate for Payer: United Healthcare Medicare Advantage |
$81.46
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$81.46
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$65.17
|
| Rate for Payer: Wellcare Medicare |
$77.39
|
|
|
IMMUNE ADMIN ORAL/NASAL
|
Facility
|
IP
|
$183.15
|
|
|
Service Code
|
HCPCS 90473
|
| Hospital Charge Code |
30301228
|
|
Hospital Revenue Code
|
771
|
| Rate for Payer: Cash Price |
$81.46
|
|
|
IMMUNE ADMIN ORAL/NASAL ADDL
|
Facility
|
OP
|
$109.89
|
|
|
Service Code
|
HCPCS 90474
|
| Hospital Charge Code |
30301229
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$4.00 |
| Max. Negotiated Rate |
$250.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$60.44
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$4.00
|
| Rate for Payer: Aetna Government |
$4.00
|
| Rate for Payer: Brighton Health Commercial |
$82.42
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$87.91
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$74.73
|
| 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 |
$54.94
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$54.94
|
| Rate for Payer: United Healthcare Commercial |
$44.00
|
|
|
IMMUNE ADMIN ORAL/NASAL ADDL
|
Facility
|
OP
|
$109.89
|
|
|
Service Code
|
HCPCS 90474
|
| Hospital Charge Code |
30101229
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$4.00 |
| Max. Negotiated Rate |
$250.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$60.44
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$4.00
|
| Rate for Payer: Aetna Government |
$4.00
|
| Rate for Payer: Brighton Health Commercial |
$233.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$204.58
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$173.89
|
| 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 |
$54.94
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$54.94
|
| Rate for Payer: United Healthcare Commercial |
$222.00
|
|
|
IMMUNE GLOBULIN (GAMMAGARD) 10% 10 GRAMS
|
Facility
|
IP
|
$13.86
|
|
|
Service Code
|
HCPCS J1569
|
| Hospital Charge Code |
41644391
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.93 |
| Max. Negotiated Rate |
$6.93 |
| Rate for Payer: Cash Price |
$44.15
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$6.93
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$6.93
|
|
|
IMMUNE GLOBULIN (GAMMAGARD) 10% 10 GRAMS
|
Facility
|
OP
|
$13.86
|
|
|
Service Code
|
HCPCS J1569
|
| Hospital Charge Code |
41644391
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.93 |
| Max. Negotiated Rate |
$3,917.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$7.62
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$44.15
|
| Rate for Payer: Aetna Government |
$44.15
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$88.13
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$88.13
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$39.17
|
| Rate for Payer: Amida Care Medicaid |
$39.17
|
| Rate for Payer: Brighton Health Commercial |
$8.32
|
| Rate for Payer: Cash Price |
$44.15
|
| Rate for Payer: Cash Price |
$44.15
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$44.15
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$6.93
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$7.97
|
| Rate for Payer: Elderplan Medicare Advantage |
$44.15
|
| Rate for Payer: EmblemHealth Commercial |
$44.15
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$3,917.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$39.17
|
| Rate for Payer: Fidelis Essential Plan QHP |
$39.17
|
| Rate for Payer: Fidelis Medicare Advantage |
$44.15
|
| Rate for Payer: Fidelis Qualified Health Plan |
$41.13
|
| Rate for Payer: Group Health Inc Commercial |
$44.15
|
| Rate for Payer: Group Health Inc Medicare |
$44.15
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$39.17
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$6.93
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$39.17
|
| Rate for Payer: Healthfirst Essential Plan |
$88.13
|
| Rate for Payer: Healthfirst Medicare Advantage |
$37.53
|
| Rate for Payer: Healthfirst QHP |
$39.17
|
| Rate for Payer: Humana Medicare |
$45.04
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$44.15
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$39.17
|
| Rate for Payer: SOMOS Essential |
$39.17
|
| Rate for Payer: United Healthcare Commercial |
$45.55
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$88.13
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$43.09
|
| Rate for Payer: United Healthcare Medicaid |
$39.17
|
| Rate for Payer: United Healthcare Medicare Advantage |
$44.15
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$9.01
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$35.32
|
| Rate for Payer: Wellcare Medicare |
$41.94
|
|
|
IMMUNE GLOBULIN (GAMMAGARD) 10% 10 GRAMS
|
Facility
|
OP
|
$13.86
|
|
|
Service Code
|
HCPCS J1569
|
| Hospital Charge Code |
41654391
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.93 |
| Max. Negotiated Rate |
$3,917.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$7.62
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$44.15
|
| Rate for Payer: Aetna Government |
$44.15
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$88.13
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$88.13
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$39.17
|
| Rate for Payer: Amida Care Medicaid |
$39.17
|
| Rate for Payer: Brighton Health Commercial |
$8.32
|
| Rate for Payer: Cash Price |
$44.15
|
| Rate for Payer: Cash Price |
$44.15
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$44.15
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$6.93
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$7.97
|
| Rate for Payer: Elderplan Medicare Advantage |
$44.15
|
| Rate for Payer: EmblemHealth Commercial |
$44.15
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$3,917.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$39.17
|
| Rate for Payer: Fidelis Essential Plan QHP |
$39.17
|
| Rate for Payer: Fidelis Medicare Advantage |
$44.15
|
| Rate for Payer: Fidelis Qualified Health Plan |
$41.13
|
| Rate for Payer: Group Health Inc Commercial |
$44.15
|
| Rate for Payer: Group Health Inc Medicare |
$44.15
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$39.17
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$6.93
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$39.17
|
| Rate for Payer: Healthfirst Essential Plan |
$88.13
|
| Rate for Payer: Healthfirst Medicare Advantage |
$37.53
|
| Rate for Payer: Healthfirst QHP |
$39.17
|
| Rate for Payer: Humana Medicare |
$45.04
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$44.15
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$39.17
|
| Rate for Payer: SOMOS Essential |
$39.17
|
| Rate for Payer: United Healthcare Commercial |
$45.55
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$88.13
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$43.09
|
| Rate for Payer: United Healthcare Medicaid |
$39.17
|
| Rate for Payer: United Healthcare Medicare Advantage |
$44.15
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$9.01
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$35.32
|
| Rate for Payer: Wellcare Medicare |
$41.94
|
|
|
IMMUNE GLOBULIN (GAMMAGARD) 10% 10 GRAMS
|
Facility
|
IP
|
$13.86
|
|
|
Service Code
|
HCPCS J1569
|
| Hospital Charge Code |
41654391
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.93 |
| Max. Negotiated Rate |
$6.93 |
| Rate for Payer: Cash Price |
$44.15
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$6.93
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$6.93
|
|
|
IMMUNE GLOBULIN (GAMMAGARD) 10% 20 GRAMS
|
Facility
|
OP
|
$27.72
|
|
|
Service Code
|
HCPCS J1569
|
| Hospital Charge Code |
41654390
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.86 |
| Max. Negotiated Rate |
$3,917.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$15.25
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$44.15
|
| Rate for Payer: Aetna Government |
$44.15
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$88.13
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$88.13
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$39.17
|
| Rate for Payer: Amida Care Medicaid |
$39.17
|
| Rate for Payer: Brighton Health Commercial |
$16.63
|
| Rate for Payer: Cash Price |
$44.15
|
| Rate for Payer: Cash Price |
$44.15
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$44.15
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$13.86
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$15.94
|
| Rate for Payer: Elderplan Medicare Advantage |
$44.15
|
| Rate for Payer: EmblemHealth Commercial |
$44.15
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$3,917.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$39.17
|
| Rate for Payer: Fidelis Essential Plan QHP |
$39.17
|
| Rate for Payer: Fidelis Medicare Advantage |
$44.15
|
| Rate for Payer: Fidelis Qualified Health Plan |
$41.13
|
| Rate for Payer: Group Health Inc Commercial |
$44.15
|
| Rate for Payer: Group Health Inc Medicare |
$44.15
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$39.17
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$13.86
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$39.17
|
| Rate for Payer: Healthfirst Essential Plan |
$88.13
|
| Rate for Payer: Healthfirst Medicare Advantage |
$37.53
|
| Rate for Payer: Healthfirst QHP |
$39.17
|
| Rate for Payer: Humana Medicare |
$45.04
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$44.15
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$39.17
|
| Rate for Payer: SOMOS Essential |
$39.17
|
| Rate for Payer: United Healthcare Commercial |
$45.55
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$88.13
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$43.09
|
| Rate for Payer: United Healthcare Medicaid |
$39.17
|
| Rate for Payer: United Healthcare Medicare Advantage |
$44.15
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$18.02
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$35.32
|
| Rate for Payer: Wellcare Medicare |
$41.94
|
|
|
IMMUNE GLOBULIN (GAMMAGARD) 10% 20 GRAMS
|
Facility
|
IP
|
$27.72
|
|
|
Service Code
|
HCPCS J1569
|
| Hospital Charge Code |
41644390
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.86 |
| Max. Negotiated Rate |
$13.86 |
| Rate for Payer: Cash Price |
$44.15
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$13.86
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$13.86
|
|
|
IMMUNE GLOBULIN (GAMMAGARD) 10% 20 GRAMS
|
Facility
|
OP
|
$27.72
|
|
|
Service Code
|
HCPCS J1569
|
| Hospital Charge Code |
41644390
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.86 |
| Max. Negotiated Rate |
$3,917.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$15.25
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$44.15
|
| Rate for Payer: Aetna Government |
$44.15
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$88.13
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$88.13
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$39.17
|
| Rate for Payer: Amida Care Medicaid |
$39.17
|
| Rate for Payer: Brighton Health Commercial |
$16.63
|
| Rate for Payer: Cash Price |
$44.15
|
| Rate for Payer: Cash Price |
$44.15
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$44.15
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$13.86
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$15.94
|
| Rate for Payer: Elderplan Medicare Advantage |
$44.15
|
| Rate for Payer: EmblemHealth Commercial |
$44.15
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$3,917.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$39.17
|
| Rate for Payer: Fidelis Essential Plan QHP |
$39.17
|
| Rate for Payer: Fidelis Medicare Advantage |
$44.15
|
| Rate for Payer: Fidelis Qualified Health Plan |
$41.13
|
| Rate for Payer: Group Health Inc Commercial |
$44.15
|
| Rate for Payer: Group Health Inc Medicare |
$44.15
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$39.17
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$13.86
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$39.17
|
| Rate for Payer: Healthfirst Essential Plan |
$88.13
|
| Rate for Payer: Healthfirst Medicare Advantage |
$37.53
|
| Rate for Payer: Healthfirst QHP |
$39.17
|
| Rate for Payer: Humana Medicare |
$45.04
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$44.15
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$39.17
|
| Rate for Payer: SOMOS Essential |
$39.17
|
| Rate for Payer: United Healthcare Commercial |
$45.55
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$88.13
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$43.09
|
| Rate for Payer: United Healthcare Medicaid |
$39.17
|
| Rate for Payer: United Healthcare Medicare Advantage |
$44.15
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$18.02
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$35.32
|
| Rate for Payer: Wellcare Medicare |
$41.94
|
|
|
IMMUNE GLOBULIN (GAMMAGARD) 10% 20 GRAMS
|
Facility
|
IP
|
$27.72
|
|
|
Service Code
|
HCPCS J1569
|
| Hospital Charge Code |
41654390
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.86 |
| Max. Negotiated Rate |
$13.86 |
| Rate for Payer: Cash Price |
$44.15
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$13.86
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$13.86
|
|
|
IMMUNE GLOBULIN (GAMMAGARD) 10% 5 GRAMS
|
Facility
|
IP
|
$810.00
|
|
|
Service Code
|
HCPCS J1569
|
| Hospital Charge Code |
41655209
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$405.00 |
| Max. Negotiated Rate |
$405.00 |
| Rate for Payer: Cash Price |
$44.15
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$405.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$405.00
|
|
|
IMMUNE GLOBULIN (GAMMAGARD) 10% 5 GRAMS
|
Facility
|
IP
|
$810.00
|
|
|
Service Code
|
HCPCS J1569
|
| Hospital Charge Code |
41645209
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$405.00 |
| Max. Negotiated Rate |
$405.00 |
| Rate for Payer: Cash Price |
$44.15
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$405.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$405.00
|
|
|
IMMUNE GLOBULIN (GAMMAGARD) 10% 5 GRAMS
|
Facility
|
OP
|
$810.00
|
|
|
Service Code
|
HCPCS J1569
|
| Hospital Charge Code |
41645209
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$35.32 |
| Max. Negotiated Rate |
$3,917.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$445.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$44.15
|
| Rate for Payer: Aetna Government |
$44.15
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$88.13
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$88.13
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$39.17
|
| Rate for Payer: Amida Care Medicaid |
$39.17
|
| Rate for Payer: Brighton Health Commercial |
$486.00
|
| Rate for Payer: Cash Price |
$44.15
|
| Rate for Payer: Cash Price |
$44.15
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$44.15
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$405.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$465.75
|
| Rate for Payer: Elderplan Medicare Advantage |
$44.15
|
| Rate for Payer: EmblemHealth Commercial |
$44.15
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$3,917.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$39.17
|
| Rate for Payer: Fidelis Essential Plan QHP |
$39.17
|
| Rate for Payer: Fidelis Medicare Advantage |
$44.15
|
| Rate for Payer: Fidelis Qualified Health Plan |
$41.13
|
| Rate for Payer: Group Health Inc Commercial |
$44.15
|
| Rate for Payer: Group Health Inc Medicare |
$44.15
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$39.17
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$405.00
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$39.17
|
| Rate for Payer: Healthfirst Essential Plan |
$88.13
|
| Rate for Payer: Healthfirst Medicare Advantage |
$37.53
|
| Rate for Payer: Healthfirst QHP |
$39.17
|
| Rate for Payer: Humana Medicare |
$45.04
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$44.15
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$39.17
|
| Rate for Payer: SOMOS Essential |
$39.17
|
| Rate for Payer: United Healthcare Commercial |
$45.55
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$88.13
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$43.09
|
| Rate for Payer: United Healthcare Medicaid |
$39.17
|
| Rate for Payer: United Healthcare Medicare Advantage |
$44.15
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$526.50
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$35.32
|
| Rate for Payer: Wellcare Medicare |
$41.94
|
|
|
IMMUNE GLOBULIN (GAMMAGARD) 10% 5 GRAMS
|
Facility
|
OP
|
$810.00
|
|
|
Service Code
|
HCPCS J1569
|
| Hospital Charge Code |
41655209
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$35.32 |
| Max. Negotiated Rate |
$3,917.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$445.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$44.15
|
| Rate for Payer: Aetna Government |
$44.15
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$88.13
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$88.13
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$39.17
|
| Rate for Payer: Amida Care Medicaid |
$39.17
|
| Rate for Payer: Brighton Health Commercial |
$486.00
|
| Rate for Payer: Cash Price |
$44.15
|
| Rate for Payer: Cash Price |
$44.15
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$44.15
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$405.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$465.75
|
| Rate for Payer: Elderplan Medicare Advantage |
$44.15
|
| Rate for Payer: EmblemHealth Commercial |
$44.15
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$3,917.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$39.17
|
| Rate for Payer: Fidelis Essential Plan QHP |
$39.17
|
| Rate for Payer: Fidelis Medicare Advantage |
$44.15
|
| Rate for Payer: Fidelis Qualified Health Plan |
$41.13
|
| Rate for Payer: Group Health Inc Commercial |
$44.15
|
| Rate for Payer: Group Health Inc Medicare |
$44.15
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$39.17
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$405.00
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$39.17
|
| Rate for Payer: Healthfirst Essential Plan |
$88.13
|
| Rate for Payer: Healthfirst Medicare Advantage |
$37.53
|
| Rate for Payer: Healthfirst QHP |
$39.17
|
| Rate for Payer: Humana Medicare |
$45.04
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$44.15
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$39.17
|
| Rate for Payer: SOMOS Essential |
$39.17
|
| Rate for Payer: United Healthcare Commercial |
$45.55
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$88.13
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$43.09
|
| Rate for Payer: United Healthcare Medicaid |
$39.17
|
| Rate for Payer: United Healthcare Medicare Advantage |
$44.15
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$526.50
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$35.32
|
| Rate for Payer: Wellcare Medicare |
$41.94
|
|
|
IMMUNE GLOBULIN (GAMMAGARD S/D) 10 GRAM
|
Facility
|
OP
|
$162.00
|
|
|
Service Code
|
HCPCS J1566
|
| Hospital Charge Code |
41643178
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$54.95 |
| Max. Negotiated Rate |
$105.30 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$89.10
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$78.50
|
| Rate for Payer: Aetna Government |
$78.50
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$54.95
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$54.95
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$54.95
|
| Rate for Payer: Brighton Health Commercial |
$97.20
|
| Rate for Payer: Cash Price |
$78.50
|
| Rate for Payer: Cash Price |
$78.50
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$78.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$81.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$93.15
|
| Rate for Payer: Elderplan Medicare Advantage |
$78.50
|
| Rate for Payer: EmblemHealth Commercial |
$78.50
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$78.50
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$78.50
|
| Rate for Payer: Fidelis Essential Plan QHP |
$82.42
|
| Rate for Payer: Fidelis Medicare Advantage |
$78.50
|
| Rate for Payer: Fidelis Qualified Health Plan |
$82.42
|
| Rate for Payer: Group Health Inc Commercial |
$78.50
|
| Rate for Payer: Group Health Inc Medicare |
$78.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$81.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$81.00
|
| Rate for Payer: Healthfirst Medicare Advantage |
$66.72
|
| Rate for Payer: Healthfirst QHP |
$78.50
|
| Rate for Payer: Humana Medicare |
$80.07
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$78.50
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$83.17
|
| Rate for Payer: SOMOS Essential |
$83.17
|
| Rate for Payer: United Healthcare Commercial |
$73.59
|
| Rate for Payer: United Healthcare Medicare Advantage |
$78.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$105.30
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$62.80
|
| Rate for Payer: Wellcare Medicare |
$74.58
|
|
|
IMMUNE GLOBULIN (GAMMAGARD S/D) 10 GRAM
|
Facility
|
OP
|
$162.00
|
|
|
Service Code
|
HCPCS J1566
|
| Hospital Charge Code |
41653178
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$54.95 |
| Max. Negotiated Rate |
$105.30 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$89.10
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$78.50
|
| Rate for Payer: Aetna Government |
$78.50
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$54.95
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$54.95
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$54.95
|
| Rate for Payer: Brighton Health Commercial |
$97.20
|
| Rate for Payer: Cash Price |
$78.50
|
| Rate for Payer: Cash Price |
$78.50
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$78.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$81.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$93.15
|
| Rate for Payer: Elderplan Medicare Advantage |
$78.50
|
| Rate for Payer: EmblemHealth Commercial |
$78.50
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$78.50
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$78.50
|
| Rate for Payer: Fidelis Essential Plan QHP |
$82.42
|
| Rate for Payer: Fidelis Medicare Advantage |
$78.50
|
| Rate for Payer: Fidelis Qualified Health Plan |
$82.42
|
| Rate for Payer: Group Health Inc Commercial |
$78.50
|
| Rate for Payer: Group Health Inc Medicare |
$78.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$81.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$81.00
|
| Rate for Payer: Healthfirst Medicare Advantage |
$66.72
|
| Rate for Payer: Healthfirst QHP |
$78.50
|
| Rate for Payer: Humana Medicare |
$80.07
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$78.50
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$83.17
|
| Rate for Payer: SOMOS Essential |
$83.17
|
| Rate for Payer: United Healthcare Commercial |
$73.59
|
| Rate for Payer: United Healthcare Medicare Advantage |
$78.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$105.30
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$62.80
|
| Rate for Payer: Wellcare Medicare |
$74.58
|
|
|
IMMUNE GLOBULIN (GAMMAGARD S/D) 10 GRAM
|
Facility
|
IP
|
$162.00
|
|
|
Service Code
|
HCPCS J1566
|
| Hospital Charge Code |
41653178
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$81.00 |
| Max. Negotiated Rate |
$81.00 |
| Rate for Payer: Cash Price |
$78.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$81.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$81.00
|
|
|
IMMUNE GLOBULIN (GAMMAGARD S/D) 10 GRAM
|
Facility
|
IP
|
$162.00
|
|
|
Service Code
|
HCPCS J1566
|
| Hospital Charge Code |
41643178
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$81.00 |
| Max. Negotiated Rate |
$81.00 |
| Rate for Payer: Cash Price |
$78.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$81.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$81.00
|
|
|
IMMUNE GLOBULIN (GAMMAGARD S/D) 2.5 GRAM
|
Facility
|
OP
|
$86.00
|
|
|
Service Code
|
HCPCS J1566
|
| Hospital Charge Code |
41653176
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$43.00 |
| Max. Negotiated Rate |
$83.17 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$47.30
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$78.50
|
| Rate for Payer: Aetna Government |
$78.50
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$54.95
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$54.95
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$54.95
|
| Rate for Payer: Brighton Health Commercial |
$51.60
|
| Rate for Payer: Cash Price |
$78.50
|
| Rate for Payer: Cash Price |
$78.50
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$78.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$43.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$49.45
|
| Rate for Payer: Elderplan Medicare Advantage |
$78.50
|
| Rate for Payer: EmblemHealth Commercial |
$78.50
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$78.50
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$78.50
|
| Rate for Payer: Fidelis Essential Plan QHP |
$82.42
|
| Rate for Payer: Fidelis Medicare Advantage |
$78.50
|
| Rate for Payer: Fidelis Qualified Health Plan |
$82.42
|
| Rate for Payer: Group Health Inc Commercial |
$78.50
|
| Rate for Payer: Group Health Inc Medicare |
$78.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$43.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$43.00
|
| Rate for Payer: Healthfirst Medicare Advantage |
$66.72
|
| Rate for Payer: Healthfirst QHP |
$78.50
|
| Rate for Payer: Humana Medicare |
$80.07
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$78.50
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$83.17
|
| Rate for Payer: SOMOS Essential |
$83.17
|
| Rate for Payer: United Healthcare Commercial |
$73.59
|
| Rate for Payer: United Healthcare Medicare Advantage |
$78.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$55.90
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$62.80
|
| Rate for Payer: Wellcare Medicare |
$74.58
|
|
|
IMMUNE GLOBULIN (GAMMAGARD S/D) 2.5 GRAM
|
Facility
|
OP
|
$86.00
|
|
|
Service Code
|
HCPCS J1566
|
| Hospital Charge Code |
41643176
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$43.00 |
| Max. Negotiated Rate |
$83.17 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$47.30
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$78.50
|
| Rate for Payer: Aetna Government |
$78.50
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$54.95
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$54.95
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$54.95
|
| Rate for Payer: Brighton Health Commercial |
$51.60
|
| Rate for Payer: Cash Price |
$78.50
|
| Rate for Payer: Cash Price |
$78.50
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$78.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$43.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$49.45
|
| Rate for Payer: Elderplan Medicare Advantage |
$78.50
|
| Rate for Payer: EmblemHealth Commercial |
$78.50
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$78.50
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$78.50
|
| Rate for Payer: Fidelis Essential Plan QHP |
$82.42
|
| Rate for Payer: Fidelis Medicare Advantage |
$78.50
|
| Rate for Payer: Fidelis Qualified Health Plan |
$82.42
|
| Rate for Payer: Group Health Inc Commercial |
$78.50
|
| Rate for Payer: Group Health Inc Medicare |
$78.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$43.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$43.00
|
| Rate for Payer: Healthfirst Medicare Advantage |
$66.72
|
| Rate for Payer: Healthfirst QHP |
$78.50
|
| Rate for Payer: Humana Medicare |
$80.07
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$78.50
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$83.17
|
| Rate for Payer: SOMOS Essential |
$83.17
|
| Rate for Payer: United Healthcare Commercial |
$73.59
|
| Rate for Payer: United Healthcare Medicare Advantage |
$78.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$55.90
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$62.80
|
| Rate for Payer: Wellcare Medicare |
$74.58
|
|
|
IMMUNE GLOBULIN (GAMMAGARD S/D) 2.5 GRAM
|
Facility
|
IP
|
$86.00
|
|
|
Service Code
|
HCPCS J1566
|
| Hospital Charge Code |
41653176
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$43.00 |
| Max. Negotiated Rate |
$43.00 |
| Rate for Payer: Cash Price |
$78.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$43.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$43.00
|
|
|
IMMUNE GLOBULIN (GAMMAGARD S/D) 2.5 GRAM
|
Facility
|
IP
|
$86.00
|
|
|
Service Code
|
HCPCS J1566
|
| Hospital Charge Code |
41643176
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$43.00 |
| Max. Negotiated Rate |
$43.00 |
| Rate for Payer: Cash Price |
$78.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$43.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$43.00
|
|
