|
CLOBETASOL PROPIONATE 0.05 % EX CREA
|
Facility
|
OP
|
$8.55
|
|
|
Service Code
|
NDC 5038326715
|
| Hospital Charge Code |
5038326715
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.99 |
| Max. Negotiated Rate |
$6.84 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$4.70
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$4.27
|
| Rate for Payer: Aetna Government |
$4.27
|
| Rate for Payer: Brighton Health Commercial |
$6.41
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$6.84
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$5.81
|
| Rate for Payer: EmblemHealth Commercial |
$4.27
|
| Rate for Payer: Group Health Inc Commercial |
$4.27
|
| Rate for Payer: Group Health Inc Medicare |
$2.99
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4.27
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4.27
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$5.56
|
|
|
CLOBETASOL PROPIONATE 0.05 % EX CREA
|
Facility
|
IP
|
$8.55
|
|
|
Service Code
|
NDC 6818095601
|
| Hospital Charge Code |
6818095601
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.27 |
| Max. Negotiated Rate |
$4.27 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4.27
|
|
|
CLOBETASOL PROPIONATE 0.05 % EX CREA
|
Facility
|
IP
|
$8.55
|
|
|
Service Code
|
NDC 5038326715
|
| Hospital Charge Code |
5038326715
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.27 |
| Max. Negotiated Rate |
$4.27 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4.27
|
|
|
CLOBETASOL PROPIONATE 0.05 % EX CREA
|
Facility
|
OP
|
$8.55
|
|
|
Service Code
|
NDC 2192201604
|
| Hospital Charge Code |
2192201604
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.99 |
| Max. Negotiated Rate |
$6.84 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$4.70
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$4.27
|
| Rate for Payer: Aetna Government |
$4.27
|
| Rate for Payer: Brighton Health Commercial |
$6.41
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$6.84
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$5.81
|
| Rate for Payer: EmblemHealth Commercial |
$4.27
|
| Rate for Payer: Group Health Inc Commercial |
$4.27
|
| Rate for Payer: Group Health Inc Medicare |
$2.99
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4.27
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4.27
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$5.56
|
|
|
CLOBETASOL PROPIONATE 0.05 % EX CREA
|
Facility
|
IP
|
$8.55
|
|
|
Service Code
|
NDC 2192201604
|
| Hospital Charge Code |
2192201604
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.27 |
| Max. Negotiated Rate |
$4.27 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4.27
|
|
|
CLOBETASOL PROPIONATE 0.05 % EX CREA
|
Facility
|
OP
|
$8.55
|
|
|
Service Code
|
NDC 2192201605
|
| Hospital Charge Code |
2192201605
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.99 |
| Max. Negotiated Rate |
$6.84 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$4.70
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$4.27
|
| Rate for Payer: Aetna Government |
$4.27
|
| Rate for Payer: Brighton Health Commercial |
$6.41
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$6.84
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$5.81
|
| Rate for Payer: EmblemHealth Commercial |
$4.27
|
| Rate for Payer: Group Health Inc Commercial |
$4.27
|
| Rate for Payer: Group Health Inc Medicare |
$2.99
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4.27
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4.27
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$5.56
|
|
|
CLOBETASOL PROPIONATE 0.05 % EX CREA
|
Facility
|
IP
|
$8.55
|
|
|
Service Code
|
NDC 2192201605
|
| Hospital Charge Code |
2192201605
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.27 |
| Max. Negotiated Rate |
$4.27 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4.27
|
|
|
CLOBETASOL PROPIONATE 0.05 % EX CREA
|
Facility
|
OP
|
$8.55
|
|
|
Service Code
|
NDC 6818095601
|
| Hospital Charge Code |
6818095601
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.99 |
| Max. Negotiated Rate |
$6.84 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$4.70
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$4.27
|
| Rate for Payer: Aetna Government |
$4.27
|
| Rate for Payer: Brighton Health Commercial |
$6.41
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$6.84
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$5.81
|
| Rate for Payer: EmblemHealth Commercial |
$4.27
|
| Rate for Payer: Group Health Inc Commercial |
$4.27
|
| Rate for Payer: Group Health Inc Medicare |
$2.99
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4.27
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4.27
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$5.56
|
|
|
CLOBETASOL PROPIONATE 0.05 % EX OINT
|
Facility
|
OP
|
$8.31
|
|
|
Service Code
|
NDC 2192201707
|
| Hospital Charge Code |
2192201707
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.91 |
| Max. Negotiated Rate |
$6.65 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$4.57
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$4.16
|
| Rate for Payer: Aetna Government |
$4.16
|
| Rate for Payer: Brighton Health Commercial |
$6.23
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$6.65
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$5.65
|
| Rate for Payer: EmblemHealth Commercial |
$4.16
|
| Rate for Payer: Group Health Inc Commercial |
$4.16
|
| Rate for Payer: Group Health Inc Medicare |
$2.91
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4.16
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4.16
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$5.40
|
|
|
CLOBETASOL PROPIONATE 0.05 % EX OINT
|
Facility
|
OP
|
$9.95
|
|
|
Service Code
|
NDC 2192201704
|
| Hospital Charge Code |
2192201704
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.48 |
| Max. Negotiated Rate |
$7.96 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$5.47
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$4.97
|
| Rate for Payer: Aetna Government |
$4.97
|
| Rate for Payer: Brighton Health Commercial |
$7.46
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$7.96
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$6.77
|
| Rate for Payer: EmblemHealth Commercial |
$4.97
|
| Rate for Payer: Group Health Inc Commercial |
$4.97
|
| Rate for Payer: Group Health Inc Medicare |
$3.48
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4.97
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4.97
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$6.47
|
|
|
CLOBETASOL PROPIONATE 0.05 % EX OINT
|
Facility
|
IP
|
$9.95
|
|
|
Service Code
|
NDC 2192201704
|
| Hospital Charge Code |
2192201704
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.97 |
| Max. Negotiated Rate |
$4.97 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4.97
|
|
|
CLOBETASOL PROPIONATE 0.05 % EX OINT
|
Facility
|
OP
|
$10.36
|
|
|
Service Code
|
NDC 5167212591
|
| Hospital Charge Code |
5167212591
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.63 |
| Max. Negotiated Rate |
$8.29 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$5.70
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$5.18
|
| Rate for Payer: Aetna Government |
$5.18
|
| Rate for Payer: Brighton Health Commercial |
$7.77
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$8.29
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$7.05
|
| Rate for Payer: EmblemHealth Commercial |
$5.18
|
| Rate for Payer: Group Health Inc Commercial |
$5.18
|
| Rate for Payer: Group Health Inc Medicare |
$3.63
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$5.18
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$5.18
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$6.74
|
|
|
CLOBETASOL PROPIONATE 0.05 % EX OINT
|
Facility
|
IP
|
$8.66
|
|
|
Service Code
|
NDC 5167212593
|
| Hospital Charge Code |
5167212593
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.33 |
| Max. Negotiated Rate |
$4.33 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4.33
|
|
|
CLOBETASOL PROPIONATE 0.05 % EX OINT
|
Facility
|
OP
|
$8.66
|
|
|
Service Code
|
NDC 5167212593
|
| Hospital Charge Code |
5167212593
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.03 |
| Max. Negotiated Rate |
$6.93 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$4.76
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$4.33
|
| Rate for Payer: Aetna Government |
$4.33
|
| Rate for Payer: Brighton Health Commercial |
$6.49
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$6.93
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$5.89
|
| Rate for Payer: EmblemHealth Commercial |
$4.33
|
| Rate for Payer: Group Health Inc Commercial |
$4.33
|
| Rate for Payer: Group Health Inc Medicare |
$3.03
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4.33
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4.33
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$5.63
|
|
|
CLOBETASOL PROPIONATE 0.05 % EX OINT
|
Facility
|
IP
|
$8.66
|
|
|
Service Code
|
NDC 4338609662
|
| Hospital Charge Code |
4338609662
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.33 |
| Max. Negotiated Rate |
$4.33 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4.33
|
|
|
CLOBETASOL PROPIONATE 0.05 % EX OINT
|
Facility
|
IP
|
$10.36
|
|
|
Service Code
|
NDC 5167212591
|
| Hospital Charge Code |
5167212591
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.18 |
| Max. Negotiated Rate |
$5.18 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$5.18
|
|
|
CLOBETASOL PROPIONATE 0.05 % EX OINT
|
Facility
|
IP
|
$8.31
|
|
|
Service Code
|
NDC 2192201707
|
| Hospital Charge Code |
2192201707
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.16 |
| Max. Negotiated Rate |
$4.16 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4.16
|
|
|
CLOBETASOL PROPIONATE 0.05 % EX OINT
|
Facility
|
OP
|
$8.66
|
|
|
Service Code
|
NDC 4338609662
|
| Hospital Charge Code |
4338609662
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.03 |
| Max. Negotiated Rate |
$6.93 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$4.76
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$4.33
|
| Rate for Payer: Aetna Government |
$4.33
|
| Rate for Payer: Brighton Health Commercial |
$6.49
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$6.93
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$5.89
|
| Rate for Payer: EmblemHealth Commercial |
$4.33
|
| Rate for Payer: Group Health Inc Commercial |
$4.33
|
| Rate for Payer: Group Health Inc Medicare |
$3.03
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4.33
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4.33
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$5.63
|
|
|
CLONAZEPAM 0.5 MG PO TABS
|
Facility
|
IP
|
$0.75
|
|
|
Service Code
|
NDC 1672913600
|
| Hospital Charge Code |
1672913600
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$0.38 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.38
|
|
|
CLONAZEPAM 0.5 MG PO TABS
|
Facility
|
IP
|
$0.75
|
|
|
Service Code
|
NDC 4354740610
|
| Hospital Charge Code |
4354740610
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$0.37 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.37
|
|
|
CLONAZEPAM 0.5 MG PO TABS
|
Facility
|
IP
|
$0.71
|
|
|
Service Code
|
NDC 6068754401
|
| Hospital Charge Code |
6068754401
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$0.35 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.35
|
|
|
CLONAZEPAM 0.5 MG PO TABS
|
Facility
|
OP
|
$0.75
|
|
|
Service Code
|
NDC 4354740610
|
| Hospital Charge Code |
4354740610
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$0.60 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.41
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.37
|
| Rate for Payer: Aetna Government |
$0.37
|
| Rate for Payer: Brighton Health Commercial |
$0.56
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.60
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.51
|
| Rate for Payer: EmblemHealth Commercial |
$0.37
|
| Rate for Payer: Group Health Inc Commercial |
$0.37
|
| Rate for Payer: Group Health Inc Medicare |
$0.26
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.37
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.37
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.49
|
|
|
CLONAZEPAM 0.5 MG PO TABS
|
Facility
|
OP
|
$0.71
|
|
|
Service Code
|
NDC 6068754401
|
| Hospital Charge Code |
6068754401
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$0.57 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.39
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.35
|
| Rate for Payer: Aetna Government |
$0.35
|
| Rate for Payer: Brighton Health Commercial |
$0.53
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.57
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.48
|
| Rate for Payer: EmblemHealth Commercial |
$0.35
|
| Rate for Payer: Group Health Inc Commercial |
$0.35
|
| Rate for Payer: Group Health Inc Medicare |
$0.25
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.35
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.35
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.46
|
|
|
CLONAZEPAM 0.5 MG PO TABS
|
Facility
|
OP
|
$0.75
|
|
|
Service Code
|
NDC 1672913600
|
| Hospital Charge Code |
1672913600
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$0.60 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.41
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.38
|
| Rate for Payer: Aetna Government |
$0.38
|
| Rate for Payer: Brighton Health Commercial |
$0.56
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.60
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.51
|
| Rate for Payer: EmblemHealth Commercial |
$0.38
|
| Rate for Payer: Group Health Inc Commercial |
$0.38
|
| Rate for Payer: Group Health Inc Medicare |
$0.26
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.38
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.38
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.49
|
|
|
CLONAZEPAM 0.5 MG PO TABS
|
Facility
|
IP
|
$0.63
|
|
|
Service Code
|
NDC 0904722761
|
| Hospital Charge Code |
0904722761
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$0.31 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.31
|
|
