|
IMMUNE GLOBULIN (HUMAN) 10 GM/100ML IV SOLN (OCTAGAM) [4080000023]
|
Facility
|
OP
|
$23.31
|
|
|
Service Code
|
HCPCS J1572
|
| Hospital Charge Code |
68982085003
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$11.66 |
| Max. Negotiated Rate |
$3,510.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$12.82
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$56.12
|
| Rate for Payer: Aetna Government |
$56.12
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$78.98
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$78.98
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$35.10
|
| Rate for Payer: Amida Care Medicaid |
$35.10
|
| Rate for Payer: Brighton Health Commercial |
$13.99
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$56.12
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$11.66
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$13.40
|
| Rate for Payer: Elderplan Medicare Advantage |
$56.12
|
| Rate for Payer: EmblemHealth Commercial |
$11.66
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$3,510.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$35.10
|
| Rate for Payer: Fidelis Essential Plan QHP |
$35.10
|
| Rate for Payer: Fidelis Medicare Advantage |
$56.12
|
| Rate for Payer: Fidelis Qualified Health Plan |
$36.86
|
| Rate for Payer: Group Health Inc Commercial |
$56.12
|
| Rate for Payer: Group Health Inc Medicare |
$56.12
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$35.10
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$11.66
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$35.10
|
| Rate for Payer: Healthfirst Essential Plan |
$78.98
|
| Rate for Payer: Healthfirst Medicare Advantage |
$47.70
|
| Rate for Payer: Healthfirst QHP |
$35.10
|
| Rate for Payer: Humana Medicare |
$57.24
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$56.12
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$35.10
|
| Rate for Payer: SOMOS Essential |
$35.10
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$78.98
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$38.61
|
| Rate for Payer: United Healthcare Medicaid |
$35.10
|
| Rate for Payer: United Healthcare Medicare Advantage |
$56.12
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$15.15
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$44.89
|
|
|
IMMUNE GLOBULIN (HUMAN) 10 GM/100ML IV SOLN (OCTAGAM) [4080000023]
|
Facility
|
IP
|
$23.31
|
|
|
Service Code
|
HCPCS J1572
|
| Hospital Charge Code |
68982085003
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$11.66 |
| Max. Negotiated Rate |
$11.66 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$11.66
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$11.66
|
|
|
IMMUNE GLOBULIN (HUMAN) 20 GM/200ML IJ SOLN [107754]
|
Facility
|
OP
|
$20.34
|
|
|
Service Code
|
HCPCS J1569
|
| Hospital Charge Code |
00944270006
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.19 |
| Max. Negotiated Rate |
$3,917.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$11.19
|
| 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 |
$15.26
|
| 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 |
$16.27
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$13.83
|
| 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 |
$44.15
|
| 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: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$43.22
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$45.82
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$45.82
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$45.82
|
| 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 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 |
$13.22
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$35.32
|
| Rate for Payer: Wellcare Medicare |
$41.94
|
|
|
IMMUNE GLOBULIN (HUMAN) 20 GM/200ML IJ SOLN [107754]
|
Facility
|
OP
|
$20.34
|
|
|
Service Code
|
HCPCS J1561
|
| Hospital Charge Code |
00944270012
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.19 |
| Max. Negotiated Rate |
$4,020.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$11.19
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$49.79
|
| Rate for Payer: Aetna Government |
$49.79
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$90.45
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$90.45
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$40.20
|
| Rate for Payer: Amida Care Medicaid |
$40.20
|
| Rate for Payer: Brighton Health Commercial |
$15.26
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$49.79
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$16.27
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$13.83
|
| Rate for Payer: Elderplan Medicare Advantage |
$49.79
|
| Rate for Payer: EmblemHealth Commercial |
$49.79
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$4,020.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$40.20
|
| Rate for Payer: Fidelis Essential Plan QHP |
$40.20
|
| Rate for Payer: Fidelis Medicare Advantage |
$49.79
|
| Rate for Payer: Fidelis Qualified Health Plan |
$42.21
|
| Rate for Payer: Group Health Inc Commercial |
$49.79
|
| Rate for Payer: Group Health Inc Medicare |
$49.79
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$40.20
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$49.79
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$40.20
|
| Rate for Payer: Healthfirst Essential Plan |
$90.45
|
| Rate for Payer: Healthfirst Medicare Advantage |
$42.32
|
| Rate for Payer: Healthfirst QHP |
$40.20
|
| Rate for Payer: Humana Medicare |
$50.78
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$48.88
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$51.82
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$51.82
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$51.82
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$49.79
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$40.20
|
| Rate for Payer: SOMOS Essential |
$40.20
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$90.45
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$44.22
|
| Rate for Payer: United Healthcare Medicaid |
$40.20
|
| Rate for Payer: United Healthcare Medicare Advantage |
$49.79
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$13.22
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$39.83
|
| Rate for Payer: Wellcare Medicare |
$47.30
|
|
|
IMMUNE GLOBULIN (HUMAN) 5 GM/100ML IV SOLN (OCTAGAM) [4080000027]
|
Facility
|
OP
|
$11.66
|
|
|
Service Code
|
HCPCS J1568
|
| Hospital Charge Code |
68982084003
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5.83 |
| Max. Negotiated Rate |
$3,905.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$6.41
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$44.98
|
| Rate for Payer: Aetna Government |
$44.98
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$87.86
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$87.86
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$39.05
|
| Rate for Payer: Amida Care Medicaid |
$39.05
|
| Rate for Payer: Brighton Health Commercial |
$6.99
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$44.98
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$5.83
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$6.70
|
| Rate for Payer: Elderplan Medicare Advantage |
$44.98
|
| Rate for Payer: EmblemHealth Commercial |
$5.83
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$3,905.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$39.05
|
| Rate for Payer: Fidelis Essential Plan QHP |
$39.05
|
| Rate for Payer: Fidelis Medicare Advantage |
$44.98
|
| Rate for Payer: Fidelis Qualified Health Plan |
$41.00
|
| Rate for Payer: Group Health Inc Commercial |
$44.98
|
| Rate for Payer: Group Health Inc Medicare |
$44.98
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$39.05
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$5.83
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$39.05
|
| Rate for Payer: Healthfirst Essential Plan |
$87.86
|
| Rate for Payer: Healthfirst Medicare Advantage |
$38.23
|
| Rate for Payer: Healthfirst QHP |
$39.05
|
| Rate for Payer: Humana Medicare |
$45.88
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$44.98
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$39.05
|
| Rate for Payer: SOMOS Essential |
$39.05
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$87.86
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$42.96
|
| Rate for Payer: United Healthcare Medicaid |
$39.05
|
| Rate for Payer: United Healthcare Medicare Advantage |
$44.98
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$7.58
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$35.98
|
|
|
IMMUNE GLOBULIN (HUMAN) 5 GM/100ML IV SOLN (OCTAGAM) [4080000027]
|
Facility
|
IP
|
$11.66
|
|
|
Service Code
|
HCPCS J1568
|
| Hospital Charge Code |
68982084003
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5.83 |
| Max. Negotiated Rate |
$5.83 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$5.83
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$5.83
|
|
|
IMMUNE GLOBULIN (HUMAN) IM INJ [15342]
|
Facility
|
OP
|
$55.11
|
|
|
Service Code
|
HCPCS J1460
|
| Hospital Charge Code |
13533063504
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$27.56 |
| Max. Negotiated Rate |
$52.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$30.31
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$50.73
|
| Rate for Payer: Aetna Government |
$50.73
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$35.51
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$35.51
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$35.51
|
| Rate for Payer: Brighton Health Commercial |
$41.33
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$50.73
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$44.09
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$37.47
|
| Rate for Payer: Elderplan Medicare Advantage |
$50.73
|
| Rate for Payer: EmblemHealth Commercial |
$50.73
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$43.12
|
| Rate for Payer: Fidelis Essential Plan QHP |
$45.15
|
| Rate for Payer: Fidelis Medicare Advantage |
$50.73
|
| Rate for Payer: Fidelis Qualified Health Plan |
$45.15
|
| Rate for Payer: Group Health Inc Commercial |
$50.73
|
| Rate for Payer: Group Health Inc Medicare |
$50.73
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$27.56
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$50.73
|
| Rate for Payer: Healthfirst Medicare Advantage |
$43.12
|
| Rate for Payer: Healthfirst QHP |
$50.73
|
| Rate for Payer: Humana Medicare |
$51.74
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$49.06
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$52.00
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$52.00
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$52.00
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$50.73
|
| Rate for Payer: United Healthcare Medicare Advantage |
$50.73
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$35.82
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$40.58
|
| Rate for Payer: Wellcare Medicare |
$48.19
|
|
|
IMMUNE GLOBULIN INJ 10 ML (FOR IM USE)
|
Facility
|
OP
|
$375.24
|
|
|
Service Code
|
HCPCS J1460
|
| Hospital Charge Code |
41654373
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$35.51 |
| Max. Negotiated Rate |
$243.91 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$206.38
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$50.73
|
| Rate for Payer: Aetna Government |
$50.73
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$35.51
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$35.51
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$35.51
|
| Rate for Payer: Brighton Health Commercial |
$225.14
|
| Rate for Payer: Cash Price |
$50.73
|
| Rate for Payer: Cash Price |
$50.73
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$50.73
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$187.62
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$215.76
|
| Rate for Payer: Elderplan Medicare Advantage |
$50.73
|
| Rate for Payer: EmblemHealth Commercial |
$50.73
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$50.73
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$50.73
|
| Rate for Payer: Fidelis Essential Plan QHP |
$53.26
|
| Rate for Payer: Fidelis Medicare Advantage |
$50.73
|
| Rate for Payer: Fidelis Qualified Health Plan |
$53.26
|
| Rate for Payer: Group Health Inc Commercial |
$50.73
|
| Rate for Payer: Group Health Inc Medicare |
$50.73
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$187.62
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$187.62
|
| Rate for Payer: Healthfirst Medicare Advantage |
$43.12
|
| Rate for Payer: Healthfirst QHP |
$50.73
|
| Rate for Payer: Humana Medicare |
$51.74
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$50.73
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$52.00
|
| Rate for Payer: SOMOS Essential |
$52.00
|
| Rate for Payer: United Healthcare Commercial |
$47.87
|
| Rate for Payer: United Healthcare Medicare Advantage |
$50.73
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$243.91
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$40.58
|
| Rate for Payer: Wellcare Medicare |
$48.19
|
|
|
IMMUNE GLOBULIN INJ 10 ML (FOR IM USE)
|
Facility
|
IP
|
$375.24
|
|
|
Service Code
|
HCPCS J1460
|
| Hospital Charge Code |
41644373
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$187.62 |
| Max. Negotiated Rate |
$187.62 |
| Rate for Payer: Cash Price |
$50.73
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$187.62
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$187.62
|
|
|
IMMUNE GLOBULIN INJ 10 ML (FOR IM USE)
|
Facility
|
IP
|
$375.24
|
|
|
Service Code
|
HCPCS J1460
|
| Hospital Charge Code |
41654373
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$187.62 |
| Max. Negotiated Rate |
$187.62 |
| Rate for Payer: Cash Price |
$50.73
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$187.62
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$187.62
|
|
|
IMMUNE GLOBULIN INJ 10 ML (FOR IM USE)
|
Facility
|
OP
|
$375.24
|
|
|
Service Code
|
HCPCS J1460
|
| Hospital Charge Code |
41644373
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$35.51 |
| Max. Negotiated Rate |
$243.91 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$206.38
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$50.73
|
| Rate for Payer: Aetna Government |
$50.73
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$35.51
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$35.51
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$35.51
|
| Rate for Payer: Brighton Health Commercial |
$225.14
|
| Rate for Payer: Cash Price |
$50.73
|
| Rate for Payer: Cash Price |
$50.73
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$50.73
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$187.62
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$215.76
|
| Rate for Payer: Elderplan Medicare Advantage |
$50.73
|
| Rate for Payer: EmblemHealth Commercial |
$50.73
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$50.73
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$50.73
|
| Rate for Payer: Fidelis Essential Plan QHP |
$53.26
|
| Rate for Payer: Fidelis Medicare Advantage |
$50.73
|
| Rate for Payer: Fidelis Qualified Health Plan |
$53.26
|
| Rate for Payer: Group Health Inc Commercial |
$50.73
|
| Rate for Payer: Group Health Inc Medicare |
$50.73
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$187.62
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$187.62
|
| Rate for Payer: Healthfirst Medicare Advantage |
$43.12
|
| Rate for Payer: Healthfirst QHP |
$50.73
|
| Rate for Payer: Humana Medicare |
$51.74
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$50.73
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$52.00
|
| Rate for Payer: SOMOS Essential |
$52.00
|
| Rate for Payer: United Healthcare Commercial |
$47.87
|
| Rate for Payer: United Healthcare Medicare Advantage |
$50.73
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$243.91
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$40.58
|
| Rate for Payer: Wellcare Medicare |
$48.19
|
|
|
IMMUNE GLOBULIN INJ 2 ML (FOR IM USE)
|
Facility
|
OP
|
$48.00
|
|
|
Service Code
|
HCPCS J1460
|
| Hospital Charge Code |
41654240
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.00 |
| Max. Negotiated Rate |
$53.26 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$26.40
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$50.73
|
| Rate for Payer: Aetna Government |
$50.73
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$35.51
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$35.51
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$35.51
|
| Rate for Payer: Brighton Health Commercial |
$28.80
|
| Rate for Payer: Cash Price |
$50.73
|
| Rate for Payer: Cash Price |
$50.73
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$50.73
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$24.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$27.60
|
| Rate for Payer: Elderplan Medicare Advantage |
$50.73
|
| Rate for Payer: EmblemHealth Commercial |
$50.73
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$50.73
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$50.73
|
| Rate for Payer: Fidelis Essential Plan QHP |
$53.26
|
| Rate for Payer: Fidelis Medicare Advantage |
$50.73
|
| Rate for Payer: Fidelis Qualified Health Plan |
$53.26
|
| Rate for Payer: Group Health Inc Commercial |
$50.73
|
| Rate for Payer: Group Health Inc Medicare |
$50.73
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$24.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$24.00
|
| Rate for Payer: Healthfirst Medicare Advantage |
$43.12
|
| Rate for Payer: Healthfirst QHP |
$50.73
|
| Rate for Payer: Humana Medicare |
$51.74
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$50.73
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$52.00
|
| Rate for Payer: SOMOS Essential |
$52.00
|
| Rate for Payer: United Healthcare Commercial |
$47.87
|
| Rate for Payer: United Healthcare Medicare Advantage |
$50.73
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$31.20
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$40.58
|
| Rate for Payer: Wellcare Medicare |
$48.19
|
|
|
IMMUNE GLOBULIN INJ 2 ML (FOR IM USE)
|
Facility
|
IP
|
$48.00
|
|
|
Service Code
|
HCPCS J1460
|
| Hospital Charge Code |
41644240
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.00 |
| Max. Negotiated Rate |
$24.00 |
| Rate for Payer: Cash Price |
$50.73
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$24.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$24.00
|
|
|
IMMUNE GLOBULIN INJ 2 ML (FOR IM USE)
|
Facility
|
OP
|
$48.00
|
|
|
Service Code
|
HCPCS J1460
|
| Hospital Charge Code |
41644240
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.00 |
| Max. Negotiated Rate |
$53.26 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$26.40
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$50.73
|
| Rate for Payer: Aetna Government |
$50.73
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$35.51
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$35.51
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$35.51
|
| Rate for Payer: Brighton Health Commercial |
$28.80
|
| Rate for Payer: Cash Price |
$50.73
|
| Rate for Payer: Cash Price |
$50.73
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$50.73
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$24.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$27.60
|
| Rate for Payer: Elderplan Medicare Advantage |
$50.73
|
| Rate for Payer: EmblemHealth Commercial |
$50.73
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$50.73
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$50.73
|
| Rate for Payer: Fidelis Essential Plan QHP |
$53.26
|
| Rate for Payer: Fidelis Medicare Advantage |
$50.73
|
| Rate for Payer: Fidelis Qualified Health Plan |
$53.26
|
| Rate for Payer: Group Health Inc Commercial |
$50.73
|
| Rate for Payer: Group Health Inc Medicare |
$50.73
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$24.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$24.00
|
| Rate for Payer: Healthfirst Medicare Advantage |
$43.12
|
| Rate for Payer: Healthfirst QHP |
$50.73
|
| Rate for Payer: Humana Medicare |
$51.74
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$50.73
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$52.00
|
| Rate for Payer: SOMOS Essential |
$52.00
|
| Rate for Payer: United Healthcare Commercial |
$47.87
|
| Rate for Payer: United Healthcare Medicare Advantage |
$50.73
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$31.20
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$40.58
|
| Rate for Payer: Wellcare Medicare |
$48.19
|
|
|
IMMUNE GLOBULIN INJ 2 ML (FOR IM USE)
|
Facility
|
IP
|
$48.00
|
|
|
Service Code
|
HCPCS J1460
|
| Hospital Charge Code |
41654240
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.00 |
| Max. Negotiated Rate |
$24.00 |
| Rate for Payer: Cash Price |
$50.73
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$24.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$24.00
|
|
|
IMMUNE GLOBULIN (OCTAGAM) 5% 5 GRAMS INJ
|
Facility
|
IP
|
$780.00
|
|
|
Service Code
|
HCPCS J1568
|
| Hospital Charge Code |
41645105
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$390.00 |
| Max. Negotiated Rate |
$390.00 |
| Rate for Payer: Cash Price |
$44.98
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$390.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$390.00
|
|
|
IMMUNE GLOBULIN (OCTAGAM) 5% 5 GRAMS INJ
|
Facility
|
OP
|
$780.00
|
|
|
Service Code
|
HCPCS J1568
|
| Hospital Charge Code |
41655105
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$35.98 |
| Max. Negotiated Rate |
$3,905.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$429.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$44.98
|
| Rate for Payer: Aetna Government |
$44.98
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$87.86
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$87.86
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$39.05
|
| Rate for Payer: Amida Care Medicaid |
$39.05
|
| Rate for Payer: Brighton Health Commercial |
$468.00
|
| Rate for Payer: Cash Price |
$44.98
|
| Rate for Payer: Cash Price |
$44.98
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$44.98
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$390.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$448.50
|
| Rate for Payer: Elderplan Medicare Advantage |
$44.98
|
| Rate for Payer: EmblemHealth Commercial |
$44.98
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$3,905.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$39.05
|
| Rate for Payer: Fidelis Essential Plan QHP |
$39.05
|
| Rate for Payer: Fidelis Medicare Advantage |
$44.98
|
| Rate for Payer: Fidelis Qualified Health Plan |
$41.00
|
| Rate for Payer: Group Health Inc Commercial |
$44.98
|
| Rate for Payer: Group Health Inc Medicare |
$44.98
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$39.05
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$390.00
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$39.05
|
| Rate for Payer: Healthfirst Essential Plan |
$87.86
|
| Rate for Payer: Healthfirst Medicare Advantage |
$38.23
|
| Rate for Payer: Healthfirst QHP |
$39.05
|
| Rate for Payer: Humana Medicare |
$45.88
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$44.98
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$39.05
|
| Rate for Payer: SOMOS Essential |
$39.05
|
| Rate for Payer: United Healthcare Commercial |
$41.07
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$87.86
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$42.96
|
| Rate for Payer: United Healthcare Medicaid |
$39.05
|
| Rate for Payer: United Healthcare Medicare Advantage |
$44.98
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$507.00
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$35.98
|
| Rate for Payer: Wellcare Medicare |
$42.73
|
|
|
IMMUNE GLOBULIN (OCTAGAM) 5% 5 GRAMS INJ
|
Facility
|
IP
|
$780.00
|
|
|
Service Code
|
HCPCS J1568
|
| Hospital Charge Code |
41655105
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$390.00 |
| Max. Negotiated Rate |
$390.00 |
| Rate for Payer: Cash Price |
$44.98
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$390.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$390.00
|
|
|
IMMUNE GLOBULIN (OCTAGAM) 5% 5 GRAMS INJ
|
Facility
|
OP
|
$780.00
|
|
|
Service Code
|
HCPCS J1568
|
| Hospital Charge Code |
41645105
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$35.98 |
| Max. Negotiated Rate |
$3,905.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$429.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$44.98
|
| Rate for Payer: Aetna Government |
$44.98
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$87.86
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$87.86
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$39.05
|
| Rate for Payer: Amida Care Medicaid |
$39.05
|
| Rate for Payer: Brighton Health Commercial |
$468.00
|
| Rate for Payer: Cash Price |
$44.98
|
| Rate for Payer: Cash Price |
$44.98
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$44.98
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$390.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$448.50
|
| Rate for Payer: Elderplan Medicare Advantage |
$44.98
|
| Rate for Payer: EmblemHealth Commercial |
$44.98
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$3,905.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$39.05
|
| Rate for Payer: Fidelis Essential Plan QHP |
$39.05
|
| Rate for Payer: Fidelis Medicare Advantage |
$44.98
|
| Rate for Payer: Fidelis Qualified Health Plan |
$41.00
|
| Rate for Payer: Group Health Inc Commercial |
$44.98
|
| Rate for Payer: Group Health Inc Medicare |
$44.98
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$39.05
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$390.00
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$39.05
|
| Rate for Payer: Healthfirst Essential Plan |
$87.86
|
| Rate for Payer: Healthfirst Medicare Advantage |
$38.23
|
| Rate for Payer: Healthfirst QHP |
$39.05
|
| Rate for Payer: Humana Medicare |
$45.88
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$44.98
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$39.05
|
| Rate for Payer: SOMOS Essential |
$39.05
|
| Rate for Payer: United Healthcare Commercial |
$41.07
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$87.86
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$42.96
|
| Rate for Payer: United Healthcare Medicaid |
$39.05
|
| Rate for Payer: United Healthcare Medicare Advantage |
$44.98
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$507.00
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$35.98
|
| Rate for Payer: Wellcare Medicare |
$42.73
|
|
|
IMMUNE GLOBULIN (WINRHO SDF) 1,500 INTL
|
Facility
|
OP
|
$34.91
|
|
|
Service Code
|
HCPCS J2792
|
| Hospital Charge Code |
41644619
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.46 |
| Max. Negotiated Rate |
$34.61 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$19.20
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$32.96
|
| Rate for Payer: Aetna Government |
$32.96
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$23.07
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$23.07
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$23.07
|
| Rate for Payer: Brighton Health Commercial |
$20.95
|
| Rate for Payer: Cash Price |
$32.96
|
| Rate for Payer: Cash Price |
$32.96
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$32.96
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$17.46
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$20.07
|
| Rate for Payer: Elderplan Medicare Advantage |
$32.96
|
| Rate for Payer: EmblemHealth Commercial |
$32.96
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$32.96
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$32.96
|
| Rate for Payer: Fidelis Essential Plan QHP |
$34.61
|
| Rate for Payer: Fidelis Medicare Advantage |
$32.96
|
| Rate for Payer: Fidelis Qualified Health Plan |
$34.61
|
| Rate for Payer: Group Health Inc Commercial |
$32.96
|
| Rate for Payer: Group Health Inc Medicare |
$32.96
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$17.46
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$17.46
|
| Rate for Payer: Healthfirst Medicare Advantage |
$28.02
|
| Rate for Payer: Healthfirst QHP |
$32.96
|
| Rate for Payer: Humana Medicare |
$33.62
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$32.96
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$32.48
|
| Rate for Payer: SOMOS Essential |
$32.48
|
| Rate for Payer: United Healthcare Commercial |
$32.92
|
| Rate for Payer: United Healthcare Medicare Advantage |
$32.96
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$22.69
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$26.37
|
| Rate for Payer: Wellcare Medicare |
$31.32
|
|
|
IMMUNE GLOBULIN (WINRHO SDF) 1,500 INTL
|
Facility
|
IP
|
$34.91
|
|
|
Service Code
|
HCPCS J2792
|
| Hospital Charge Code |
41644619
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.46 |
| Max. Negotiated Rate |
$17.46 |
| Rate for Payer: Cash Price |
$32.96
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$17.46
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$17.46
|
|
|
IMMUNE GLOBULIN (WINRHO SDF) 1,500 INTL
|
Facility
|
OP
|
$34.91
|
|
|
Service Code
|
HCPCS J2792
|
| Hospital Charge Code |
41654619
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.46 |
| Max. Negotiated Rate |
$34.61 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$19.20
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$32.96
|
| Rate for Payer: Aetna Government |
$32.96
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$23.07
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$23.07
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$23.07
|
| Rate for Payer: Brighton Health Commercial |
$20.95
|
| Rate for Payer: Cash Price |
$32.96
|
| Rate for Payer: Cash Price |
$32.96
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$32.96
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$17.46
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$20.07
|
| Rate for Payer: Elderplan Medicare Advantage |
$32.96
|
| Rate for Payer: EmblemHealth Commercial |
$32.96
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$32.96
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$32.96
|
| Rate for Payer: Fidelis Essential Plan QHP |
$34.61
|
| Rate for Payer: Fidelis Medicare Advantage |
$32.96
|
| Rate for Payer: Fidelis Qualified Health Plan |
$34.61
|
| Rate for Payer: Group Health Inc Commercial |
$32.96
|
| Rate for Payer: Group Health Inc Medicare |
$32.96
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$17.46
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$17.46
|
| Rate for Payer: Healthfirst Medicare Advantage |
$28.02
|
| Rate for Payer: Healthfirst QHP |
$32.96
|
| Rate for Payer: Humana Medicare |
$33.62
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$32.96
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$32.48
|
| Rate for Payer: SOMOS Essential |
$32.48
|
| Rate for Payer: United Healthcare Commercial |
$32.92
|
| Rate for Payer: United Healthcare Medicare Advantage |
$32.96
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$22.69
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$26.37
|
| Rate for Payer: Wellcare Medicare |
$31.32
|
|
|
IMMUNE GLOBULIN (WINRHO SDF) 1,500 INTL
|
Facility
|
IP
|
$34.91
|
|
|
Service Code
|
HCPCS J2792
|
| Hospital Charge Code |
41654619
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.46 |
| Max. Negotiated Rate |
$17.46 |
| Rate for Payer: Cash Price |
$32.96
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$17.46
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$17.46
|
|
|
IMMUNE GLOBULIN (WINRHO SDF) 5,000 INTL
|
Facility
|
IP
|
$34.91
|
|
|
Service Code
|
HCPCS J2792
|
| Hospital Charge Code |
41644558
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.46 |
| Max. Negotiated Rate |
$17.46 |
| Rate for Payer: Cash Price |
$32.96
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$17.46
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$17.46
|
|
|
IMMUNE GLOBULIN (WINRHO SDF) 5,000 INTL
|
Facility
|
IP
|
$34.91
|
|
|
Service Code
|
HCPCS J2792
|
| Hospital Charge Code |
41654558
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.46 |
| Max. Negotiated Rate |
$17.46 |
| Rate for Payer: Cash Price |
$32.96
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$17.46
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$17.46
|
|
