|
INTERCOSTAL NERVE
|
Facility
|
IP
|
$2,459.50
|
|
|
Service Code
|
HCPCS 64620
|
| Hospital Charge Code |
30305726
|
|
Hospital Revenue Code
|
510
|
| Rate for Payer: Cash Price |
$1,054.06
|
|
|
INTERCOSTAL NERVE MULTIPLE
|
Facility
|
IP
|
$2,459.50
|
|
|
Service Code
|
HCPCS 64421
|
| Hospital Charge Code |
30305030
|
|
Hospital Revenue Code
|
510
|
| Rate for Payer: Cash Price |
$1,054.06
|
|
|
INTERCOSTAL NERVE MULTIPLE
|
Facility
|
OP
|
$2,459.50
|
|
|
Service Code
|
HCPCS 64421
|
| Hospital Charge Code |
30305030
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$222.00 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,412.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,054.06
|
| Rate for Payer: Aetna Government |
$1,054.06
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$737.84
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$737.84
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$737.84
|
| Rate for Payer: Brighton Health Commercial |
$233.00
|
| Rate for Payer: Cash Price |
$1,054.06
|
| Rate for Payer: Cash Price |
$1,054.06
|
| Rate for Payer: Cash Price |
$1,054.06
|
| Rate for Payer: Cash Price |
$1,054.06
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,054.06
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2,915.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,477.75
|
| Rate for Payer: Elderplan Medicare Advantage |
$1,054.06
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$895.95
|
| Rate for Payer: Fidelis Essential Plan QHP |
$938.11
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,054.06
|
| Rate for Payer: Fidelis Qualified Health Plan |
$938.11
|
| 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 |
$1,229.75
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,054.06
|
| Rate for Payer: Healthfirst Medicare Advantage |
$895.95
|
| Rate for Payer: Healthfirst QHP |
$1,054.06
|
| Rate for Payer: Humana Medicare |
$1,075.14
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$1,054.06
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,054.06
|
| Rate for Payer: United Healthcare Commercial |
$222.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,054.06
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,054.06
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$843.25
|
| Rate for Payer: Wellcare Medicare |
$1,001.36
|
|
|
INTERCOSTAL NERVE,SINGLE
|
Facility
|
OP
|
$1,898.00
|
|
|
Service Code
|
HCPCS 64420
|
| Hospital Charge Code |
30305029
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$222.00 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,412.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$799.72
|
| Rate for Payer: Aetna Government |
$799.72
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$559.80
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$559.80
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$559.80
|
| Rate for Payer: Brighton Health Commercial |
$233.00
|
| Rate for Payer: Cash Price |
$799.72
|
| Rate for Payer: Cash Price |
$799.72
|
| Rate for Payer: Cash Price |
$799.72
|
| Rate for Payer: Cash Price |
$799.72
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$799.72
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2,915.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,477.75
|
| Rate for Payer: Elderplan Medicare Advantage |
$799.72
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$679.76
|
| Rate for Payer: Fidelis Essential Plan QHP |
$711.75
|
| Rate for Payer: Fidelis Medicare Advantage |
$799.72
|
| Rate for Payer: Fidelis Qualified Health Plan |
$711.75
|
| 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 |
$949.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$799.72
|
| Rate for Payer: Healthfirst Medicare Advantage |
$679.76
|
| Rate for Payer: Healthfirst QHP |
$799.72
|
| Rate for Payer: Humana Medicare |
$815.71
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$799.72
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$799.72
|
| Rate for Payer: United Healthcare Commercial |
$222.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$799.72
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$799.72
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$639.78
|
| Rate for Payer: Wellcare Medicare |
$759.73
|
|
|
INTERCOSTAL NERVE,SINGLE
|
Facility
|
IP
|
$1,898.00
|
|
|
Service Code
|
HCPCS 64420
|
| Hospital Charge Code |
30305029
|
|
Hospital Revenue Code
|
510
|
| Rate for Payer: Cash Price |
$799.72
|
|
|
INTERDENTAL WIRING
|
Facility
|
IP
|
$4,086.83
|
|
|
Service Code
|
HCPCS 21497
|
| Hospital Charge Code |
30105567
|
|
Hospital Revenue Code
|
450
|
| Rate for Payer: Cash Price |
$1,763.60
|
|
|
INTERDENTAL WIRING
|
Facility
|
OP
|
$4,086.83
|
|
|
Service Code
|
HCPCS 21497
|
| Hospital Charge Code |
30105567
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$165.00 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,888.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,763.60
|
| Rate for Payer: Aetna Government |
$1,763.60
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$1,234.52
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$1,234.52
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$1,234.52
|
| Rate for Payer: Brighton Health Commercial |
$874.00
|
| Rate for Payer: Carelon Behavioral Health CHP/Medicaid |
$1,763.60
|
| Rate for Payer: Carelon Behavioral Health Medicare Advantage |
$1,763.60
|
| Rate for Payer: Cash Price |
$1,763.60
|
| Rate for Payer: Cash Price |
$1,763.60
|
| Rate for Payer: Cash Price |
$1,763.60
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,763.60
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2,915.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,477.75
|
| Rate for Payer: Elderplan Medicare Advantage |
$1,763.60
|
| Rate for Payer: EmblemHealth Commercial |
$525.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$1,499.06
|
| Rate for Payer: Fidelis Essential Plan QHP |
$1,569.60
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,763.60
|
| Rate for Payer: Fidelis Qualified Health Plan |
$1,569.60
|
| Rate for Payer: Group Health Inc Commercial |
$525.00
|
| Rate for Payer: Group Health Inc Medicare |
$525.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,043.42
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,763.60
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$165.00
|
| Rate for Payer: Healthfirst Medicare Advantage |
$225.00
|
| Rate for Payer: Healthfirst QHP |
$1,763.60
|
| Rate for Payer: Humana Medicare |
$1,798.87
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$1,763.60
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,763.60
|
| Rate for Payer: United Healthcare Commercial |
$569.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,763.60
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,763.60
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$1,410.88
|
| Rate for Payer: Wellcare Medicare |
$1,675.42
|
|
|
INTERDENTAL WIRING
|
Facility
|
OP
|
$4,086.83
|
|
|
Service Code
|
HCPCS 21497
|
| Hospital Charge Code |
30305567
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$165.00 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,888.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,763.60
|
| Rate for Payer: Aetna Government |
$1,763.60
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$1,234.52
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$1,234.52
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$1,234.52
|
| Rate for Payer: Brighton Health Commercial |
$874.00
|
| Rate for Payer: Carelon Behavioral Health CHP/Medicaid |
$1,763.60
|
| Rate for Payer: Carelon Behavioral Health Medicare Advantage |
$1,763.60
|
| Rate for Payer: Cash Price |
$1,763.60
|
| Rate for Payer: Cash Price |
$1,763.60
|
| Rate for Payer: Cash Price |
$1,763.60
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,763.60
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2,915.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,477.75
|
| Rate for Payer: Elderplan Medicare Advantage |
$1,763.60
|
| Rate for Payer: EmblemHealth Commercial |
$525.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$1,499.06
|
| Rate for Payer: Fidelis Essential Plan QHP |
$1,569.60
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,763.60
|
| Rate for Payer: Fidelis Qualified Health Plan |
$1,569.60
|
| Rate for Payer: Group Health Inc Commercial |
$525.00
|
| Rate for Payer: Group Health Inc Medicare |
$525.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,043.42
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,763.60
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$165.00
|
| Rate for Payer: Healthfirst Medicare Advantage |
$225.00
|
| Rate for Payer: Healthfirst QHP |
$1,763.60
|
| Rate for Payer: Humana Medicare |
$1,798.87
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$1,763.60
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,763.60
|
| Rate for Payer: United Healthcare Commercial |
$569.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,763.60
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,763.60
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$1,410.88
|
| Rate for Payer: Wellcare Medicare |
$1,675.42
|
|
|
INTERDENTAL WIRING
|
Facility
|
IP
|
$4,086.83
|
|
|
Service Code
|
HCPCS 21497
|
| Hospital Charge Code |
30305567
|
|
Hospital Revenue Code
|
450
|
| Rate for Payer: Cash Price |
$1,763.60
|
|
|
INTERFERON ALFA 2B 3,000,000 UNITS/0.2 M
|
Facility
|
OP
|
$438.00
|
|
|
Service Code
|
HCPCS J9214
|
| Hospital Charge Code |
41643512
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.80 |
| Max. Negotiated Rate |
$284.70 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$240.90
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$32.57
|
| Rate for Payer: Aetna Government |
$32.57
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$22.80
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$22.80
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$22.80
|
| Rate for Payer: Brighton Health Commercial |
$262.80
|
| Rate for Payer: Cash Price |
$32.57
|
| Rate for Payer: Cash Price |
$32.57
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$32.57
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$219.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$251.85
|
| Rate for Payer: Elderplan Medicare Advantage |
$32.57
|
| Rate for Payer: EmblemHealth Commercial |
$32.57
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$32.57
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$32.57
|
| Rate for Payer: Fidelis Essential Plan QHP |
$34.20
|
| Rate for Payer: Fidelis Medicare Advantage |
$32.57
|
| Rate for Payer: Fidelis Qualified Health Plan |
$34.20
|
| Rate for Payer: Group Health Inc Commercial |
$32.57
|
| Rate for Payer: Group Health Inc Medicare |
$32.57
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$219.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$219.00
|
| Rate for Payer: Healthfirst Medicare Advantage |
$27.69
|
| Rate for Payer: Healthfirst QHP |
$32.57
|
| Rate for Payer: Humana Medicare |
$33.23
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$32.57
|
| Rate for Payer: United Healthcare Commercial |
$32.57
|
| Rate for Payer: United Healthcare Medicare Advantage |
$32.57
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$284.70
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$26.06
|
| Rate for Payer: Wellcare Medicare |
$30.95
|
|
|
INTERFERON ALFA 2B 3,000,000 UNITS/0.2 M
|
Facility
|
IP
|
$438.00
|
|
|
Service Code
|
HCPCS J9214
|
| Hospital Charge Code |
41653512
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$219.00 |
| Max. Negotiated Rate |
$219.00 |
| Rate for Payer: Cash Price |
$32.57
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$219.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$219.00
|
|
|
INTERFERON ALFA 2B 3,000,000 UNITS/0.2 M
|
Facility
|
IP
|
$438.00
|
|
|
Service Code
|
HCPCS J9214
|
| Hospital Charge Code |
41643512
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$219.00 |
| Max. Negotiated Rate |
$219.00 |
| Rate for Payer: Cash Price |
$32.57
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$219.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$219.00
|
|
|
INTERFERON ALFA 2B 3,000,000 UNITS/0.2 M
|
Facility
|
OP
|
$438.00
|
|
|
Service Code
|
HCPCS J9214
|
| Hospital Charge Code |
41653512
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.80 |
| Max. Negotiated Rate |
$284.70 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$240.90
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$32.57
|
| Rate for Payer: Aetna Government |
$32.57
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$22.80
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$22.80
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$22.80
|
| Rate for Payer: Brighton Health Commercial |
$262.80
|
| Rate for Payer: Cash Price |
$32.57
|
| Rate for Payer: Cash Price |
$32.57
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$32.57
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$219.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$251.85
|
| Rate for Payer: Elderplan Medicare Advantage |
$32.57
|
| Rate for Payer: EmblemHealth Commercial |
$32.57
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$32.57
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$32.57
|
| Rate for Payer: Fidelis Essential Plan QHP |
$34.20
|
| Rate for Payer: Fidelis Medicare Advantage |
$32.57
|
| Rate for Payer: Fidelis Qualified Health Plan |
$34.20
|
| Rate for Payer: Group Health Inc Commercial |
$32.57
|
| Rate for Payer: Group Health Inc Medicare |
$32.57
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$219.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$219.00
|
| Rate for Payer: Healthfirst Medicare Advantage |
$27.69
|
| Rate for Payer: Healthfirst QHP |
$32.57
|
| Rate for Payer: Humana Medicare |
$33.23
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$32.57
|
| Rate for Payer: United Healthcare Commercial |
$32.57
|
| Rate for Payer: United Healthcare Medicare Advantage |
$32.57
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$284.70
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$26.06
|
| Rate for Payer: Wellcare Medicare |
$30.95
|
|
|
INTERFERON ALFA 2B 5,000,000 UNITS/0.2 M
|
Facility
|
IP
|
$730.00
|
|
|
Service Code
|
HCPCS J9214
|
| Hospital Charge Code |
41653513
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$365.00 |
| Max. Negotiated Rate |
$365.00 |
| Rate for Payer: Cash Price |
$32.57
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$365.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$365.00
|
|
|
INTERFERON ALFA 2B 5,000,000 UNITS/0.2 M
|
Facility
|
OP
|
$730.00
|
|
|
Service Code
|
HCPCS J9214
|
| Hospital Charge Code |
41653513
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.80 |
| Max. Negotiated Rate |
$474.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$401.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$32.57
|
| Rate for Payer: Aetna Government |
$32.57
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$22.80
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$22.80
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$22.80
|
| Rate for Payer: Brighton Health Commercial |
$438.00
|
| Rate for Payer: Cash Price |
$32.57
|
| Rate for Payer: Cash Price |
$32.57
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$32.57
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$365.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$419.75
|
| Rate for Payer: Elderplan Medicare Advantage |
$32.57
|
| Rate for Payer: EmblemHealth Commercial |
$32.57
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$32.57
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$32.57
|
| Rate for Payer: Fidelis Essential Plan QHP |
$34.20
|
| Rate for Payer: Fidelis Medicare Advantage |
$32.57
|
| Rate for Payer: Fidelis Qualified Health Plan |
$34.20
|
| Rate for Payer: Group Health Inc Commercial |
$32.57
|
| Rate for Payer: Group Health Inc Medicare |
$32.57
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$365.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$365.00
|
| Rate for Payer: Healthfirst Medicare Advantage |
$27.69
|
| Rate for Payer: Healthfirst QHP |
$32.57
|
| Rate for Payer: Humana Medicare |
$33.23
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$32.57
|
| Rate for Payer: United Healthcare Commercial |
$32.57
|
| Rate for Payer: United Healthcare Medicare Advantage |
$32.57
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$474.50
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$26.06
|
| Rate for Payer: Wellcare Medicare |
$30.95
|
|
|
INTERFERON ALFA 2B 5,000,000 UNITS/0.2 M
|
Facility
|
IP
|
$730.00
|
|
|
Service Code
|
HCPCS J9214
|
| Hospital Charge Code |
41643513
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$365.00 |
| Max. Negotiated Rate |
$365.00 |
| Rate for Payer: Cash Price |
$32.57
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$365.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$365.00
|
|
|
INTERFERON ALFA 2B 5,000,000 UNITS/0.2 M
|
Facility
|
OP
|
$730.00
|
|
|
Service Code
|
HCPCS J9214
|
| Hospital Charge Code |
41643513
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.80 |
| Max. Negotiated Rate |
$474.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$401.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$32.57
|
| Rate for Payer: Aetna Government |
$32.57
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$22.80
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$22.80
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$22.80
|
| Rate for Payer: Brighton Health Commercial |
$438.00
|
| Rate for Payer: Cash Price |
$32.57
|
| Rate for Payer: Cash Price |
$32.57
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$32.57
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$365.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$419.75
|
| Rate for Payer: Elderplan Medicare Advantage |
$32.57
|
| Rate for Payer: EmblemHealth Commercial |
$32.57
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$32.57
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$32.57
|
| Rate for Payer: Fidelis Essential Plan QHP |
$34.20
|
| Rate for Payer: Fidelis Medicare Advantage |
$32.57
|
| Rate for Payer: Fidelis Qualified Health Plan |
$34.20
|
| Rate for Payer: Group Health Inc Commercial |
$32.57
|
| Rate for Payer: Group Health Inc Medicare |
$32.57
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$365.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$365.00
|
| Rate for Payer: Healthfirst Medicare Advantage |
$27.69
|
| Rate for Payer: Healthfirst QHP |
$32.57
|
| Rate for Payer: Humana Medicare |
$33.23
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$32.57
|
| Rate for Payer: United Healthcare Commercial |
$32.57
|
| Rate for Payer: United Healthcare Medicare Advantage |
$32.57
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$474.50
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$26.06
|
| Rate for Payer: Wellcare Medicare |
$30.95
|
|
|
INTERFERON ALFA 2B 6,000,000 UNITS/ML IN
|
Facility
|
OP
|
$463.00
|
|
|
Service Code
|
HCPCS J9214
|
| Hospital Charge Code |
41653052
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.80 |
| Max. Negotiated Rate |
$300.95 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$254.65
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$32.57
|
| Rate for Payer: Aetna Government |
$32.57
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$22.80
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$22.80
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$22.80
|
| Rate for Payer: Brighton Health Commercial |
$277.80
|
| Rate for Payer: Cash Price |
$32.57
|
| Rate for Payer: Cash Price |
$32.57
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$32.57
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$231.50
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$266.22
|
| Rate for Payer: Elderplan Medicare Advantage |
$32.57
|
| Rate for Payer: EmblemHealth Commercial |
$32.57
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$32.57
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$32.57
|
| Rate for Payer: Fidelis Essential Plan QHP |
$34.20
|
| Rate for Payer: Fidelis Medicare Advantage |
$32.57
|
| Rate for Payer: Fidelis Qualified Health Plan |
$34.20
|
| Rate for Payer: Group Health Inc Commercial |
$32.57
|
| Rate for Payer: Group Health Inc Medicare |
$32.57
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$231.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$231.50
|
| Rate for Payer: Healthfirst Medicare Advantage |
$27.69
|
| Rate for Payer: Healthfirst QHP |
$32.57
|
| Rate for Payer: Humana Medicare |
$33.23
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$32.57
|
| Rate for Payer: United Healthcare Commercial |
$32.57
|
| Rate for Payer: United Healthcare Medicare Advantage |
$32.57
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$300.95
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$26.06
|
| Rate for Payer: Wellcare Medicare |
$30.95
|
|
|
INTERFERON ALFA 2B 6,000,000 UNITS/ML IN
|
Facility
|
IP
|
$463.00
|
|
|
Service Code
|
HCPCS J9214
|
| Hospital Charge Code |
41653052
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$231.50 |
| Max. Negotiated Rate |
$231.50 |
| Rate for Payer: Cash Price |
$32.57
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$231.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$231.50
|
|
|
INTERFERON ALFA 2B 6,000,000 UNITS/ML IN
|
Facility
|
OP
|
$463.00
|
|
|
Service Code
|
HCPCS J9214
|
| Hospital Charge Code |
41643052
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.80 |
| Max. Negotiated Rate |
$300.95 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$254.65
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$32.57
|
| Rate for Payer: Aetna Government |
$32.57
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$22.80
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$22.80
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$22.80
|
| Rate for Payer: Brighton Health Commercial |
$277.80
|
| Rate for Payer: Cash Price |
$32.57
|
| Rate for Payer: Cash Price |
$32.57
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$32.57
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$231.50
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$266.22
|
| Rate for Payer: Elderplan Medicare Advantage |
$32.57
|
| Rate for Payer: EmblemHealth Commercial |
$32.57
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$32.57
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$32.57
|
| Rate for Payer: Fidelis Essential Plan QHP |
$34.20
|
| Rate for Payer: Fidelis Medicare Advantage |
$32.57
|
| Rate for Payer: Fidelis Qualified Health Plan |
$34.20
|
| Rate for Payer: Group Health Inc Commercial |
$32.57
|
| Rate for Payer: Group Health Inc Medicare |
$32.57
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$231.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$231.50
|
| Rate for Payer: Healthfirst Medicare Advantage |
$27.69
|
| Rate for Payer: Healthfirst QHP |
$32.57
|
| Rate for Payer: Humana Medicare |
$33.23
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$32.57
|
| Rate for Payer: United Healthcare Commercial |
$32.57
|
| Rate for Payer: United Healthcare Medicare Advantage |
$32.57
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$300.95
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$26.06
|
| Rate for Payer: Wellcare Medicare |
$30.95
|
|
|
INTERFERON ALFA 2B 6,000,000 UNITS/ML IN
|
Facility
|
IP
|
$463.00
|
|
|
Service Code
|
HCPCS J9214
|
| Hospital Charge Code |
41643052
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$231.50 |
| Max. Negotiated Rate |
$231.50 |
| Rate for Payer: Cash Price |
$32.57
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$231.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$231.50
|
|
|
INTERFERON BETA-1A 30 MCG/0.5ML IM PSKT [129666]
|
Facility
|
OP
|
$9,919.01
|
|
|
Service Code
|
HCPCS Q3027
|
| Hospital Charge Code |
59627022205
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.58 |
| Max. Negotiated Rate |
$7,935.21 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$5,455.46
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$53.69
|
| Rate for Payer: Aetna Government |
$53.69
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$37.58
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$37.58
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$37.58
|
| Rate for Payer: Brighton Health Commercial |
$7,439.26
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$53.69
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$7,935.21
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$6,744.93
|
| Rate for Payer: Elderplan Medicare Advantage |
$53.69
|
| Rate for Payer: EmblemHealth Commercial |
$53.69
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$45.64
|
| Rate for Payer: Fidelis Essential Plan QHP |
$47.78
|
| Rate for Payer: Fidelis Medicare Advantage |
$53.69
|
| Rate for Payer: Fidelis Qualified Health Plan |
$47.78
|
| Rate for Payer: Group Health Inc Commercial |
$53.69
|
| Rate for Payer: Group Health Inc Medicare |
$53.69
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4,959.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$53.69
|
| Rate for Payer: Healthfirst Medicare Advantage |
$45.64
|
| Rate for Payer: Healthfirst QHP |
$53.69
|
| Rate for Payer: Humana Medicare |
$54.76
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$54.28
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$57.54
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$57.54
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$57.54
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$53.69
|
| Rate for Payer: United Healthcare Medicare Advantage |
$53.69
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$6,447.36
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$42.95
|
| Rate for Payer: Wellcare Medicare |
$51.01
|
|
|
INTERFERON BETA-1A 44 MCG/0.5ML SC SOSY [129669]
|
Facility
|
OP
|
$2,113.14
|
|
|
Service Code
|
NDC 44087004403
|
| Hospital Charge Code |
44087004403
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$739.60 |
| Max. Negotiated Rate |
$1,690.51 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,162.23
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,056.57
|
| Rate for Payer: Aetna Government |
$1,056.57
|
| Rate for Payer: Brighton Health Commercial |
$1,584.85
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,690.51
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,436.93
|
| Rate for Payer: Group Health Inc Commercial |
$1,056.57
|
| Rate for Payer: Group Health Inc Medicare |
$739.60
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,056.57
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,056.57
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,373.54
|
|
|
INTERFERON BETA 1A (AVONEX) 30 MCG INJ
|
Facility
|
OP
|
$69.42
|
|
|
Service Code
|
HCPCS Q3027
|
| Hospital Charge Code |
41645070
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.71 |
| Max. Negotiated Rate |
$57.54 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$38.18
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$53.69
|
| Rate for Payer: Aetna Government |
$53.69
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$37.58
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$37.58
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$37.58
|
| Rate for Payer: Brighton Health Commercial |
$41.65
|
| Rate for Payer: Cash Price |
$53.69
|
| Rate for Payer: Cash Price |
$53.69
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$53.69
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$34.71
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$39.92
|
| Rate for Payer: Elderplan Medicare Advantage |
$53.69
|
| Rate for Payer: EmblemHealth Commercial |
$53.69
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$53.69
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$53.69
|
| Rate for Payer: Fidelis Essential Plan QHP |
$56.38
|
| Rate for Payer: Fidelis Medicare Advantage |
$53.69
|
| Rate for Payer: Fidelis Qualified Health Plan |
$56.38
|
| Rate for Payer: Group Health Inc Commercial |
$53.69
|
| Rate for Payer: Group Health Inc Medicare |
$53.69
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$34.71
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$34.71
|
| Rate for Payer: Healthfirst Medicare Advantage |
$45.64
|
| Rate for Payer: Healthfirst QHP |
$53.69
|
| Rate for Payer: Humana Medicare |
$54.76
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$53.69
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$57.54
|
| Rate for Payer: SOMOS Essential |
$57.54
|
| Rate for Payer: United Healthcare Commercial |
$54.42
|
| Rate for Payer: United Healthcare Medicare Advantage |
$53.69
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$45.12
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$42.95
|
| Rate for Payer: Wellcare Medicare |
$51.01
|
|
|
INTERFERON BETA 1A (AVONEX) 30 MCG INJ
|
Facility
|
IP
|
$69.42
|
|
|
Service Code
|
HCPCS Q3027
|
| Hospital Charge Code |
41645070
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.71 |
| Max. Negotiated Rate |
$34.71 |
| Rate for Payer: Cash Price |
$53.69
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$34.71
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$34.71
|
|
