|
GROUP THERAPY CHILD
|
Facility
|
OP
|
$750.00
|
|
|
Service Code
|
HCPCS 90853
|
| Hospital Charge Code |
4511521
|
|
Hospital Revenue Code
|
915
|
| Min. Negotiated Rate |
$21.30 |
| Max. Negotiated Rate |
$437.80 |
| Rate for Payer: Aetna Commercial |
$328.28
|
| Rate for Payer: Aetna Medicare Advantage |
$391.04
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$437.80
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$437.80
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage |
$120.69
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$36.62
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$437.80
|
| Rate for Payer: Cigna Commercial |
$241.93
|
| Rate for Payer: Cigna Medicare Advantage |
$120.69
|
| Rate for Payer: Clover Medicare Advantage |
$114.66
|
| Rate for Payer: EmblemHealth Commercial |
$362.07
|
| Rate for Payer: Humana Medicare Advantage |
$124.31
|
| Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage |
$120.69
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$195.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$112.50
|
| Rate for Payer: UnitedHealthcare Community & State |
$23.70
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$120.69
|
| Rate for Payer: Wellcare Medicare Advantage |
$120.69
|
| Rate for Payer: Wellcare New Jersey Medicaid/Family Care |
$27.48
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$21.30
|
|
|
GROUP THERAPY CHILD
|
Facility
|
OP
|
$750.00
|
|
|
Service Code
|
HCPCS 90853
|
| Hospital Charge Code |
4517521
|
|
Hospital Revenue Code
|
915
|
| Min. Negotiated Rate |
$21.30 |
| Max. Negotiated Rate |
$437.80 |
| Rate for Payer: Aetna Commercial |
$328.28
|
| Rate for Payer: Aetna Medicare Advantage |
$391.04
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$437.80
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$437.80
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage |
$120.69
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$36.62
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$437.80
|
| Rate for Payer: Cigna Commercial |
$241.93
|
| Rate for Payer: Cigna Medicare Advantage |
$120.69
|
| Rate for Payer: Clover Medicare Advantage |
$114.66
|
| Rate for Payer: EmblemHealth Commercial |
$362.07
|
| Rate for Payer: Humana Medicare Advantage |
$124.31
|
| Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage |
$120.69
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$195.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$112.50
|
| Rate for Payer: UnitedHealthcare Community & State |
$23.70
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$120.69
|
| Rate for Payer: Wellcare Medicare Advantage |
$120.69
|
| Rate for Payer: Wellcare New Jersey Medicaid/Family Care |
$27.48
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$21.30
|
|
|
GROUP THERAPY CHILD
|
Facility
|
OP
|
$750.00
|
|
|
Service Code
|
HCPCS 90853
|
| Hospital Charge Code |
4546521
|
|
Hospital Revenue Code
|
915
|
| Min. Negotiated Rate |
$21.30 |
| Max. Negotiated Rate |
$437.80 |
| Rate for Payer: Aetna Commercial |
$328.28
|
| Rate for Payer: Aetna Medicare Advantage |
$391.04
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$437.80
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$437.80
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage |
$120.69
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$36.62
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$437.80
|
| Rate for Payer: Cigna Commercial |
$241.93
|
| Rate for Payer: Cigna Medicare Advantage |
$120.69
|
| Rate for Payer: Clover Medicare Advantage |
$114.66
|
| Rate for Payer: EmblemHealth Commercial |
$362.07
|
| Rate for Payer: Humana Medicare Advantage |
$124.31
|
| Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage |
$120.69
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$195.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$112.50
|
| Rate for Payer: UnitedHealthcare Community & State |
$23.70
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$120.69
|
| Rate for Payer: Wellcare Medicare Advantage |
$120.69
|
| Rate for Payer: Wellcare New Jersey Medicaid/Family Care |
$27.48
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$21.30
|
|
|
GROUP THERAPY CHILD
|
Facility
|
IP
|
$750.00
|
|
|
Service Code
|
HCPCS 90853
|
| Hospital Charge Code |
4832521
|
|
Hospital Revenue Code
|
915
|
| Min. Negotiated Rate |
$112.50 |
| Max. Negotiated Rate |
$112.50 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$112.50
|
|
|
GROUP THERAPY CHILD
|
Facility
|
OP
|
$750.00
|
|
|
Service Code
|
HCPCS 90853
|
| Hospital Charge Code |
4832521
|
|
Hospital Revenue Code
|
915
|
| Min. Negotiated Rate |
$21.30 |
| Max. Negotiated Rate |
$437.80 |
| Rate for Payer: Aetna Commercial |
$328.28
|
| Rate for Payer: Aetna Medicare Advantage |
$391.04
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$437.80
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$437.80
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage |
$120.69
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$36.62
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$437.80
|
| Rate for Payer: Cigna Commercial |
$241.93
|
| Rate for Payer: Cigna Medicare Advantage |
$120.69
|
| Rate for Payer: Clover Medicare Advantage |
$114.66
|
| Rate for Payer: EmblemHealth Commercial |
$362.07
|
| Rate for Payer: Humana Medicare Advantage |
$124.31
|
| Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage |
$120.69
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$195.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$112.50
|
| Rate for Payer: UnitedHealthcare Community & State |
$23.70
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$120.69
|
| Rate for Payer: Wellcare Medicare Advantage |
$120.69
|
| Rate for Payer: Wellcare New Jersey Medicaid/Family Care |
$27.48
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$21.30
|
|
|
GROUP THERAPY CHILD
|
Facility
|
OP
|
$750.00
|
|
|
Service Code
|
HCPCS 90853
|
| Hospital Charge Code |
4822521
|
|
Hospital Revenue Code
|
915
|
| Min. Negotiated Rate |
$21.30 |
| Max. Negotiated Rate |
$437.80 |
| Rate for Payer: Aetna Commercial |
$328.28
|
| Rate for Payer: Aetna Medicare Advantage |
$391.04
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$437.80
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$437.80
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage |
$120.69
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$36.62
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$437.80
|
| Rate for Payer: Cigna Commercial |
$241.93
|
| Rate for Payer: Cigna Medicare Advantage |
$120.69
|
| Rate for Payer: Clover Medicare Advantage |
$114.66
|
| Rate for Payer: EmblemHealth Commercial |
$362.07
|
| Rate for Payer: Humana Medicare Advantage |
$124.31
|
| Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage |
$120.69
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$195.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$112.50
|
| Rate for Payer: UnitedHealthcare Community & State |
$23.70
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$120.69
|
| Rate for Payer: Wellcare Medicare Advantage |
$120.69
|
| Rate for Payer: Wellcare New Jersey Medicaid/Family Care |
$27.48
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$21.30
|
|
|
GROUP THERAPY CHILD
|
Facility
|
OP
|
$750.00
|
|
|
Service Code
|
HCPCS 90853
|
| Hospital Charge Code |
4515521
|
|
Hospital Revenue Code
|
915
|
| Min. Negotiated Rate |
$21.30 |
| Max. Negotiated Rate |
$437.80 |
| Rate for Payer: Aetna Commercial |
$328.28
|
| Rate for Payer: Aetna Medicare Advantage |
$391.04
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$437.80
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$437.80
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage |
$120.69
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$36.62
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$437.80
|
| Rate for Payer: Cigna Commercial |
$241.93
|
| Rate for Payer: Cigna Medicare Advantage |
$120.69
|
| Rate for Payer: Clover Medicare Advantage |
$114.66
|
| Rate for Payer: EmblemHealth Commercial |
$362.07
|
| Rate for Payer: Humana Medicare Advantage |
$124.31
|
| Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage |
$120.69
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$195.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$112.50
|
| Rate for Payer: UnitedHealthcare Community & State |
$23.70
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$120.69
|
| Rate for Payer: Wellcare Medicare Advantage |
$120.69
|
| Rate for Payer: Wellcare New Jersey Medicaid/Family Care |
$27.48
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$21.30
|
|
|
GROUP THERAPY CHILD
|
Facility
|
IP
|
$750.00
|
|
|
Service Code
|
HCPCS 90853
|
| Hospital Charge Code |
4822521
|
|
Hospital Revenue Code
|
915
|
| Min. Negotiated Rate |
$112.50 |
| Max. Negotiated Rate |
$112.50 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$112.50
|
|
|
GROWTH HORMONE
|
Facility
|
OP
|
$114.65
|
|
|
Service Code
|
HCPCS 83003
|
| Hospital Charge Code |
39900089
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$3.26 |
| Max. Negotiated Rate |
$156.00 |
| Rate for Payer: Aetna Commercial |
$45.34
|
| Rate for Payer: Aetna Medicare Advantage |
$54.01
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$60.47
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$60.47
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage |
$16.67
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$26.40
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$60.47
|
| Rate for Payer: Cigna Commercial |
$57.33
|
| Rate for Payer: Cigna Medicare Advantage |
$16.67
|
| Rate for Payer: Clover Medicare Advantage |
$15.84
|
| Rate for Payer: EmblemHealth Commercial |
$50.01
|
| Rate for Payer: Humana Medicare Advantage |
$17.17
|
| Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage |
$16.67
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$29.81
|
| Rate for Payer: Oxford Commercial |
$156.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$17.20
|
| Rate for Payer: UnitedHealthcare Commercial |
$156.00
|
| Rate for Payer: UnitedHealthcare Community & State |
$13.34
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$16.67
|
| Rate for Payer: Wellcare Medicare Advantage |
$16.67
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$3.26
|
|
|
GROWTH HORMONE
|
Facility
|
OP
|
$390.00
|
|
|
Service Code
|
HCPCS 83003
|
| Hospital Charge Code |
38472329
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$11.08 |
| Max. Negotiated Rate |
$195.00 |
| Rate for Payer: Aetna Commercial |
$45.34
|
| Rate for Payer: Aetna Medicare Advantage |
$54.01
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$60.47
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$60.47
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage |
$16.67
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$26.40
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$60.47
|
| Rate for Payer: Cigna Commercial |
$195.00
|
| Rate for Payer: Cigna Medicare Advantage |
$16.67
|
| Rate for Payer: Clover Medicare Advantage |
$15.84
|
| Rate for Payer: EmblemHealth Commercial |
$50.01
|
| Rate for Payer: Humana Medicare Advantage |
$17.17
|
| Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage |
$16.67
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$101.40
|
| Rate for Payer: Oxford Commercial |
$156.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$58.50
|
| Rate for Payer: UnitedHealthcare Commercial |
$156.00
|
| Rate for Payer: UnitedHealthcare Community & State |
$13.34
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$16.67
|
| Rate for Payer: Wellcare Medicare Advantage |
$16.67
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$11.08
|
|
|
GROWTH HORMONE
|
Facility
|
IP
|
$390.00
|
|
|
Service Code
|
HCPCS 83003
|
| Hospital Charge Code |
38472329
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$58.50 |
| Max. Negotiated Rate |
$58.50 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$58.50
|
|
|
GROWTH HORMONE
|
Facility
|
IP
|
$114.65
|
|
|
Service Code
|
HCPCS 83003
|
| Hospital Charge Code |
39900089
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$17.20 |
| Max. Negotiated Rate |
$17.20 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$17.20
|
|
|
G TUBE BALLOON REPL 18FR 6218
|
Facility
|
IP
|
$136.50
|
|
| Hospital Charge Code |
270629060
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$20.48 |
| Max. Negotiated Rate |
$20.48 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$20.48
|
|
|
G TUBE BALLOON REPL 18FR 6218
|
Facility
|
OP
|
$136.50
|
|
| Hospital Charge Code |
270629060
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3.88 |
| Max. Negotiated Rate |
$68.25 |
| Rate for Payer: Aetna Commercial |
$51.87
|
| Rate for Payer: Aetna Medicare Advantage |
$40.95
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$34.81
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$34.81
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$34.81
|
| Rate for Payer: Cigna Commercial |
$68.25
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$35.49
|
| Rate for Payer: Oxford Commercial |
$27.30
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$20.48
|
| Rate for Payer: UnitedHealthcare Commercial |
$27.30
|
| Rate for Payer: UnitedHealthcare Community & State |
$4.31
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$3.88
|
|
|
GUAIFENESIN 100 MG/5 ML LIQ
|
Facility
|
OP
|
$4.02
|
|
|
Service Code
|
NDC 121174405
|
| Hospital Charge Code |
60627996
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$2.01 |
| Rate for Payer: Aetna Commercial |
$1.53
|
| Rate for Payer: Aetna Medicare Advantage |
$1.21
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$1.03
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$1.03
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$1.03
|
| Rate for Payer: Cigna Commercial |
$2.01
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$1.05
|
| Rate for Payer: Oxford Commercial |
$0.80
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$0.60
|
| Rate for Payer: UnitedHealthcare Commercial |
$0.80
|
| Rate for Payer: UnitedHealthcare Community & State |
$0.13
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$0.11
|
|
|
GUAIFENESIN 100 MG/5 ML LIQ
|
Facility
|
IP
|
$4.02
|
|
|
Service Code
|
NDC 121174405
|
| Hospital Charge Code |
60627996
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$0.60 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$0.60
|
|
|
GUAIFENESIN 200MG/10ML LIQ UD
|
Facility
|
OP
|
$4.29
|
|
|
Service Code
|
NDC 121174410
|
| Hospital Charge Code |
60629924
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$2.15 |
| Rate for Payer: Aetna Commercial |
$1.63
|
| Rate for Payer: Aetna Medicare Advantage |
$1.29
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$1.09
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$1.09
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$1.09
|
| Rate for Payer: Cigna Commercial |
$2.15
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$1.12
|
| Rate for Payer: Oxford Commercial |
$0.86
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$0.64
|
| Rate for Payer: UnitedHealthcare Commercial |
$0.86
|
| Rate for Payer: UnitedHealthcare Community & State |
$0.14
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$0.12
|
|
|
GUAIFENESIN 200MG/10ML LIQ UD
|
Facility
|
IP
|
$4.29
|
|
|
Service Code
|
NDC 121174410
|
| Hospital Charge Code |
60629924
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.64 |
| Max. Negotiated Rate |
$0.64 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$0.64
|
|
|
GUAIFENESIN 600 MG CR TAB
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 45802049878
|
| Hospital Charge Code |
60627997
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$2.00 |
| Rate for Payer: Aetna Commercial |
$1.52
|
| Rate for Payer: Aetna Medicare Advantage |
$1.20
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$1.02
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$1.02
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$1.02
|
| Rate for Payer: Cigna Commercial |
$2.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$1.04
|
| Rate for Payer: Oxford Commercial |
$0.80
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$0.60
|
| Rate for Payer: UnitedHealthcare Commercial |
$0.80
|
| Rate for Payer: UnitedHealthcare Community & State |
$0.13
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$0.11
|
|
|
GUAIFENESIN 600 MG CR TAB
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 45802049878
|
| Hospital Charge Code |
60627997
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$0.60 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$0.60
|
|
|
GUAIFENESIN-COD 100-10mg 10ML
|
Facility
|
OP
|
$5.03
|
|
|
Service Code
|
NDC 121177510
|
| Hospital Charge Code |
60629334
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$2.52 |
| Rate for Payer: Aetna Commercial |
$1.91
|
| Rate for Payer: Aetna Medicare Advantage |
$1.51
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$1.28
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$1.28
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$1.28
|
| Rate for Payer: Cigna Commercial |
$2.52
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$1.31
|
| Rate for Payer: Oxford Commercial |
$1.01
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$0.75
|
| Rate for Payer: UnitedHealthcare Commercial |
$1.01
|
| Rate for Payer: UnitedHealthcare Community & State |
$0.16
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$0.14
|
|
|
GUAIFENESIN-COD 100-10mg 10ML
|
Facility
|
IP
|
$5.03
|
|
|
Service Code
|
NDC 121177510
|
| Hospital Charge Code |
60629334
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$0.75 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$0.75
|
|
|
GUAIFENESN COD 100-10MG/5ML
|
Facility
|
IP
|
$4.36
|
|
|
Service Code
|
NDC 121177505
|
| Hospital Charge Code |
60627985
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$0.65 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$0.65
|
|
|
GUAIFENESN COD 100-10MG/5ML
|
Facility
|
OP
|
$4.36
|
|
|
Service Code
|
NDC 121177505
|
| Hospital Charge Code |
60627985
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$2.18 |
| Rate for Payer: Aetna Commercial |
$1.66
|
| Rate for Payer: Aetna Medicare Advantage |
$1.31
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$1.11
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$1.11
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$1.11
|
| Rate for Payer: Cigna Commercial |
$2.18
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$1.13
|
| Rate for Payer: Oxford Commercial |
$0.87
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$0.65
|
| Rate for Payer: UnitedHealthcare Commercial |
$0.87
|
| Rate for Payer: UnitedHealthcare Community & State |
$0.14
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$0.12
|
|
|
GUAIFENESN DM 100-10MG 5ML UD
|
Facility
|
OP
|
$4.36
|
|
|
Service Code
|
NDC 121063805
|
| Hospital Charge Code |
60627998
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$2.18 |
| Rate for Payer: Aetna Commercial |
$1.66
|
| Rate for Payer: Aetna Medicare Advantage |
$1.31
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$1.11
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$1.11
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$1.11
|
| Rate for Payer: Cigna Commercial |
$2.18
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$1.13
|
| Rate for Payer: Oxford Commercial |
$0.87
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$0.65
|
| Rate for Payer: UnitedHealthcare Commercial |
$0.87
|
| Rate for Payer: UnitedHealthcare Community & State |
$0.14
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$0.12
|
|
