|
MIRTAZAPINE 15 MG PO TABS [17466]
|
Facility
|
OP
|
$2.72
|
|
|
Service Code
|
NDC 60505024701
|
| Hospital Charge Code |
60505024701
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.95 |
| Max. Negotiated Rate |
$2.17 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.49
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.36
|
| Rate for Payer: Aetna Government |
$1.36
|
| Rate for Payer: Brighton Health Commercial |
$2.04
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2.17
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.85
|
| Rate for Payer: Group Health Inc Commercial |
$1.36
|
| Rate for Payer: Group Health Inc Medicare |
$0.95
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.36
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.36
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.76
|
|
|
MIRTAZAPINE 15 MG TAB
|
Facility
|
OP
|
$0.30
|
|
| Hospital Charge Code |
41653128
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.24 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.17
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.15
|
| Rate for Payer: Aetna Government |
$0.15
|
| Rate for Payer: Brighton Health Commercial |
$0.23
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.24
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.20
|
| Rate for Payer: Group Health Inc Commercial |
$0.15
|
| Rate for Payer: Group Health Inc Medicare |
$0.11
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.15
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.15
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.20
|
|
|
MIRTAZAPINE 15 MG TAB
|
Facility
|
OP
|
$0.30
|
|
| Hospital Charge Code |
41643128
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.24 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.17
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.15
|
| Rate for Payer: Aetna Government |
$0.15
|
| Rate for Payer: Brighton Health Commercial |
$0.23
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.24
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.20
|
| Rate for Payer: Group Health Inc Commercial |
$0.15
|
| Rate for Payer: Group Health Inc Medicare |
$0.11
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.15
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.15
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.20
|
|
|
MIRTAZAPINE 30 MG PO TABS [17465]
|
Facility
|
OP
|
$0.21
|
|
|
Service Code
|
NDC 63739009910
|
| Hospital Charge Code |
63739009910
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.11
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.10
|
| Rate for Payer: Aetna Government |
$0.10
|
| Rate for Payer: Brighton Health Commercial |
$0.16
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.17
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.14
|
| Rate for Payer: Group Health Inc Commercial |
$0.10
|
| Rate for Payer: Group Health Inc Medicare |
$0.07
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.10
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.10
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.13
|
|
|
MIRTAZAPINE 30 MG PO TABS [17465]
|
Facility
|
OP
|
$1.29
|
|
|
Service Code
|
NDC 68084012011
|
| Hospital Charge Code |
68084012011
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.45 |
| Max. Negotiated Rate |
$1.03 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.71
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.65
|
| Rate for Payer: Aetna Government |
$0.65
|
| Rate for Payer: Brighton Health Commercial |
$0.97
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.03
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.88
|
| Rate for Payer: Group Health Inc Commercial |
$0.65
|
| Rate for Payer: Group Health Inc Medicare |
$0.45
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.65
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.65
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.84
|
|
|
MIRTAZAPINE 30 MG PO TABS [17465]
|
Facility
|
OP
|
$2.77
|
|
|
Service Code
|
NDC 13107000334
|
| Hospital Charge Code |
13107000334
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.97 |
| Max. Negotiated Rate |
$2.21 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.52
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.38
|
| Rate for Payer: Aetna Government |
$1.38
|
| Rate for Payer: Brighton Health Commercial |
$2.08
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2.21
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.88
|
| Rate for Payer: Group Health Inc Commercial |
$1.38
|
| Rate for Payer: Group Health Inc Medicare |
$0.97
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.38
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.38
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.80
|
|
|
MIRTAZAPINE 30 MG TAB
|
Facility
|
OP
|
$0.44
|
|
| Hospital Charge Code |
41643127
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.35 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.24
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.22
|
| Rate for Payer: Aetna Government |
$0.22
|
| Rate for Payer: Brighton Health Commercial |
$0.33
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.35
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.30
|
| Rate for Payer: Group Health Inc Commercial |
$0.22
|
| Rate for Payer: Group Health Inc Medicare |
$0.15
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.22
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.22
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.29
|
|
|
MIRTAZAPINE 30 MG TAB
|
Facility
|
OP
|
$0.44
|
|
| Hospital Charge Code |
41653127
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.35 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.24
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.22
|
| Rate for Payer: Aetna Government |
$0.22
|
| Rate for Payer: Brighton Health Commercial |
$0.33
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.35
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.30
|
| Rate for Payer: Group Health Inc Commercial |
$0.22
|
| Rate for Payer: Group Health Inc Medicare |
$0.15
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.22
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.22
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.29
|
|
|
MIRTAZAPINE 45 MG PO TABS [24945]
|
Facility
|
OP
|
$2.85
|
|
|
Service Code
|
NDC 68084012101
|
| Hospital Charge Code |
68084012101
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$2.28 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.57
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.42
|
| Rate for Payer: Aetna Government |
$1.42
|
| Rate for Payer: Brighton Health Commercial |
$2.14
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2.28
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.94
|
| Rate for Payer: Group Health Inc Commercial |
$1.42
|
| Rate for Payer: Group Health Inc Medicare |
$1.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.42
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.42
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.85
|
|
|
MIRTAZAPINE 45 MG PO TABS [24945]
|
Facility
|
OP
|
$2.85
|
|
|
Service Code
|
NDC 00378354593
|
| Hospital Charge Code |
00378354593
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$2.28 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.57
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.42
|
| Rate for Payer: Aetna Government |
$1.42
|
| Rate for Payer: Brighton Health Commercial |
$2.14
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2.28
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.94
|
| Rate for Payer: Group Health Inc Commercial |
$1.42
|
| Rate for Payer: Group Health Inc Medicare |
$1.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.42
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.42
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.85
|
|
|
MIRTAZAPINE 45 MG PO TABS [24945]
|
Facility
|
OP
|
$2.83
|
|
|
Service Code
|
NDC 13107003234
|
| Hospital Charge Code |
13107003234
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.99 |
| Max. Negotiated Rate |
$2.27 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.56
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.42
|
| Rate for Payer: Aetna Government |
$1.42
|
| Rate for Payer: Brighton Health Commercial |
$2.12
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2.27
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.93
|
| Rate for Payer: Group Health Inc Commercial |
$1.42
|
| Rate for Payer: Group Health Inc Medicare |
$0.99
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.42
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.42
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.84
|
|
|
MIRTAZAPINE 45 MG PO TABS [24945]
|
Facility
|
OP
|
$2.85
|
|
|
Service Code
|
NDC 60505024901
|
| Hospital Charge Code |
60505024901
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$2.28 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.57
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.43
|
| Rate for Payer: Aetna Government |
$1.43
|
| Rate for Payer: Brighton Health Commercial |
$2.14
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2.28
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.94
|
| Rate for Payer: Group Health Inc Commercial |
$1.43
|
| Rate for Payer: Group Health Inc Medicare |
$1.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.43
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.43
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.85
|
|
|
MIRTAZAPINE 45 MG PO TABS [24945]
|
Facility
|
OP
|
$2.85
|
|
|
Service Code
|
NDC 68084012111
|
| Hospital Charge Code |
68084012111
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$2.28 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.57
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.42
|
| Rate for Payer: Aetna Government |
$1.42
|
| Rate for Payer: Brighton Health Commercial |
$2.14
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2.28
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.94
|
| Rate for Payer: Group Health Inc Commercial |
$1.42
|
| Rate for Payer: Group Health Inc Medicare |
$1.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.42
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.42
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.85
|
|
|
MIRTAZAPINE 45 MG TAB
|
Facility
|
OP
|
$0.52
|
|
| Hospital Charge Code |
41655297
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.42 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.29
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.26
|
| Rate for Payer: Aetna Government |
$0.26
|
| Rate for Payer: Brighton Health Commercial |
$0.39
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.42
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.35
|
| Rate for Payer: Group Health Inc Commercial |
$0.26
|
| Rate for Payer: Group Health Inc Medicare |
$0.18
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.26
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.26
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.34
|
|
|
MIRTAZAPINE 45 MG TAB
|
Facility
|
OP
|
$0.52
|
|
| Hospital Charge Code |
41645297
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.42 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.29
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.26
|
| Rate for Payer: Aetna Government |
$0.26
|
| Rate for Payer: Brighton Health Commercial |
$0.39
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.42
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.35
|
| Rate for Payer: Group Health Inc Commercial |
$0.26
|
| Rate for Payer: Group Health Inc Medicare |
$0.18
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.26
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.26
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.34
|
|
|
MIRVETUXIMAB SORAVTANSINE-GYNX 100 MG/20ML IV SOLN [188825]
|
Facility
|
OP
|
$380.66
|
|
|
Service Code
|
HCPCS J9063
|
| Hospital Charge Code |
72903085301
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$52.57 |
| Max. Negotiated Rate |
$247.43 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$209.37
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$65.71
|
| Rate for Payer: Aetna Government |
$65.71
|
| Rate for Payer: Brighton Health Commercial |
$228.40
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$65.71
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$190.33
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$218.88
|
| Rate for Payer: Elderplan Medicare Advantage |
$65.71
|
| Rate for Payer: EmblemHealth Commercial |
$190.33
|
| Rate for Payer: Fidelis Medicare Advantage |
$65.71
|
| Rate for Payer: Group Health Inc Commercial |
$65.71
|
| Rate for Payer: Group Health Inc Medicare |
$65.71
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$190.33
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$190.33
|
| Rate for Payer: Healthfirst Medicare Advantage |
$55.85
|
| Rate for Payer: Healthfirst QHP |
$65.71
|
| Rate for Payer: Humana Medicare |
$67.02
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$65.71
|
| Rate for Payer: United Healthcare Medicare Advantage |
$65.71
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$247.43
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$52.57
|
|
|
MIRVETUXIMAB SORAVTANSINE-GYNX 100 MG/20ML IV SOLN [188825]
|
Facility
|
IP
|
$380.66
|
|
|
Service Code
|
HCPCS J9063
|
| Hospital Charge Code |
72903085301
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$190.33 |
| Max. Negotiated Rate |
$190.33 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$190.33
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$190.33
|
|
|
MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC
|
Facility
|
IP
|
$35,153.57
|
|
|
Service Code
|
MSDRG 640
|
| Min. Negotiated Rate |
$11,277.80 |
| Max. Negotiated Rate |
$35,153.57 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$19,392.62
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$25,566.23
|
| Rate for Payer: Aetna Government |
$25,566.23
|
| Rate for Payer: Brighton Health Commercial |
$19,070.40
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$26,077.55
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$22,712.19
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$18,743.07
|
| Rate for Payer: Elderplan Medicare Advantage |
$24,287.92
|
| Rate for Payer: EmblemHealth Commercial |
$11,277.80
|
| Rate for Payer: Fidelis Medicare Advantage |
$25,566.23
|
| Rate for Payer: Group Health Inc Commercial |
$25,566.23
|
| Rate for Payer: Group Health Inc Medicare |
$25,566.23
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$25,566.23
|
| Rate for Payer: Healthfirst Medicare Advantage |
$11,888.30
|
| Rate for Payer: Humana Medicare |
$35,153.57
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$25,566.23
|
| Rate for Payer: United Healthcare Commercial |
$26,155.38
|
| Rate for Payer: United Healthcare Medicare Advantage |
$25,566.23
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$25,566.23
|
| Rate for Payer: Wellcare Medicare |
$24,287.92
|
|
|
MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC
|
Facility
|
IP
|
$24,975.25
|
|
|
Service Code
|
MSDRG 641
|
| Min. Negotiated Rate |
$6,700.51 |
| Max. Negotiated Rate |
$24,975.25 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$11,521.74
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$18,163.82
|
| Rate for Payer: Aetna Government |
$18,163.82
|
| Rate for Payer: Brighton Health Commercial |
$11,330.30
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$18,527.10
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$13,494.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$11,135.83
|
| Rate for Payer: Elderplan Medicare Advantage |
$17,255.63
|
| Rate for Payer: EmblemHealth Commercial |
$6,700.51
|
| Rate for Payer: Fidelis Medicare Advantage |
$18,163.82
|
| Rate for Payer: Group Health Inc Commercial |
$18,163.82
|
| Rate for Payer: Group Health Inc Medicare |
$18,163.82
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$18,163.82
|
| Rate for Payer: Healthfirst Medicare Advantage |
$8,446.18
|
| Rate for Payer: Humana Medicare |
$24,975.25
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$18,163.82
|
| Rate for Payer: United Healthcare Commercial |
$15,539.70
|
| Rate for Payer: United Healthcare Medicare Advantage |
$18,163.82
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$18,163.82
|
| Rate for Payer: Wellcare Medicare |
$17,255.63
|
|
|
MISOPROSTOL 100 MCG PO TABS [10628]
|
Facility
|
OP
|
$2.48
|
|
|
Service Code
|
NDC 68084004011
|
| Hospital Charge Code |
68084004011
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.87 |
| Max. Negotiated Rate |
$1.98 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.36
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.24
|
| Rate for Payer: Aetna Government |
$1.24
|
| Rate for Payer: Brighton Health Commercial |
$1.86
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.98
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.69
|
| Rate for Payer: Group Health Inc Commercial |
$1.24
|
| Rate for Payer: Group Health Inc Medicare |
$0.87
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.24
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.24
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.61
|
|
|
MISOPROSTOL 100 MCG PO TABS [10628]
|
Facility
|
OP
|
$0.82
|
|
|
Service Code
|
NDC 59762500701
|
| Hospital Charge Code |
59762500701
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$0.66 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.45
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.41
|
| Rate for Payer: Aetna Government |
$0.41
|
| Rate for Payer: Brighton Health Commercial |
$0.62
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.66
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.56
|
| Rate for Payer: Group Health Inc Commercial |
$0.41
|
| Rate for Payer: Group Health Inc Medicare |
$0.29
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.41
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.41
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.54
|
|
|
MISOPROSTOL 100 MCG PO TABS [10628]
|
Facility
|
OP
|
$0.98
|
|
|
Service Code
|
NDC 70954044310
|
| Hospital Charge Code |
70954044310
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$0.78 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.54
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.49
|
| Rate for Payer: Aetna Government |
$0.49
|
| Rate for Payer: Brighton Health Commercial |
$0.74
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.78
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.67
|
| Rate for Payer: Group Health Inc Commercial |
$0.49
|
| Rate for Payer: Group Health Inc Medicare |
$0.34
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.49
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.49
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.64
|
|
|
MISOPROSTOL 100 MCG TAB
|
Facility
|
OP
|
$3.24
|
|
| Hospital Charge Code |
41642222
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.13 |
| Max. Negotiated Rate |
$2.59 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.78
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.62
|
| Rate for Payer: Aetna Government |
$1.62
|
| Rate for Payer: Brighton Health Commercial |
$2.43
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2.59
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2.20
|
| Rate for Payer: Group Health Inc Commercial |
$1.62
|
| Rate for Payer: Group Health Inc Medicare |
$1.13
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.62
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.62
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2.11
|
|
|
MISOPROSTOL 100 MCG TAB
|
Facility
|
OP
|
$3.24
|
|
| Hospital Charge Code |
41652222
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.13 |
| Max. Negotiated Rate |
$2.59 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.78
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.62
|
| Rate for Payer: Aetna Government |
$1.62
|
| Rate for Payer: Brighton Health Commercial |
$2.43
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2.59
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2.20
|
| Rate for Payer: Group Health Inc Commercial |
$1.62
|
| Rate for Payer: Group Health Inc Medicare |
$1.13
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.62
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.62
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2.11
|
|
|
MISOPROSTOL 200 MCG PO TABS [10629]
|
Facility
|
OP
|
$2.73
|
|
|
Service Code
|
NDC 68084004111
|
| Hospital Charge Code |
68084004111
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.96 |
| Max. Negotiated Rate |
$2.18 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.36
|
| Rate for Payer: Aetna Government |
$1.36
|
| Rate for Payer: Brighton Health Commercial |
$2.05
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2.18
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.86
|
| Rate for Payer: Group Health Inc Commercial |
$1.36
|
| Rate for Payer: Group Health Inc Medicare |
$0.96
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.36
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.36
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.77
|
|
