|
SUGAMMADEX 500MG/5ML INJ
|
Facility
OP
|
$432.59
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
41646627
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$151.41 |
| Max. Negotiated Rate |
$281.18 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$237.92
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$216.30
|
| Rate for Payer: Aetna Government |
$216.30
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$216.30
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$248.74
|
| Rate for Payer: Group Health Inc Commercial |
$216.30
|
| Rate for Payer: Group Health Inc Medicare |
$151.41
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$216.30
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$216.30
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$281.18
|
|
|
SULFACETAMIDE 10% OPHTHALMIC SOLN
|
Facility
OP
|
$17.36
|
|
| Hospital Charge Code |
41654368
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.08 |
| Max. Negotiated Rate |
$13.89 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$9.55
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$8.68
|
| Rate for Payer: Aetna Government |
$8.68
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$13.89
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$11.80
|
| Rate for Payer: Group Health Inc Commercial |
$8.68
|
| Rate for Payer: Group Health Inc Medicare |
$6.08
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$8.68
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$8.68
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$11.28
|
|
|
SULFACETAMIDE 10% OPHTHALMIC SOLN
|
Facility
OP
|
$17.36
|
|
| Hospital Charge Code |
41644368
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.08 |
| Max. Negotiated Rate |
$13.89 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$9.55
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$8.68
|
| Rate for Payer: Aetna Government |
$8.68
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$13.89
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$11.80
|
| Rate for Payer: Group Health Inc Commercial |
$8.68
|
| Rate for Payer: Group Health Inc Medicare |
$6.08
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$8.68
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$8.68
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$11.28
|
|
|
SULFACETAMIDE + PREDNISOLONE SUSPENSION
|
Facility
OP
|
$24.00
|
|
| Hospital Charge Code |
41650522
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.40 |
| Max. Negotiated Rate |
$19.20 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$13.20
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$12.00
|
| Rate for Payer: Aetna Government |
$12.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$19.20
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$16.32
|
| Rate for Payer: Group Health Inc Commercial |
$12.00
|
| Rate for Payer: Group Health Inc Medicare |
$8.40
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$12.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$12.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$15.60
|
|
|
SULFACETAMIDE + PREDNISOLONE SUSPENSION
|
Facility
OP
|
$24.00
|
|
| Hospital Charge Code |
41640522
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.40 |
| Max. Negotiated Rate |
$19.20 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$13.20
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$12.00
|
| Rate for Payer: Aetna Government |
$12.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$19.20
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$16.32
|
| Rate for Payer: Group Health Inc Commercial |
$12.00
|
| Rate for Payer: Group Health Inc Medicare |
$8.40
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$12.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$12.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$15.60
|
|
|
SULFADIAZINE 500 MG TAB
|
Facility
OP
|
$5.00
|
|
| Hospital Charge Code |
41643470
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.75 |
| Max. Negotiated Rate |
$4.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2.75
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.50
|
| Rate for Payer: Aetna Government |
$2.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$4.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$3.40
|
| Rate for Payer: Group Health Inc Commercial |
$2.50
|
| Rate for Payer: Group Health Inc Medicare |
$1.75
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3.25
|
|
|
SULFADIAZINE 500 MG TAB
|
Facility
OP
|
$5.00
|
|
| Hospital Charge Code |
41653470
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.75 |
| Max. Negotiated Rate |
$4.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2.75
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.50
|
| Rate for Payer: Aetna Government |
$2.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$4.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$3.40
|
| Rate for Payer: Group Health Inc Commercial |
$2.50
|
| Rate for Payer: Group Health Inc Medicare |
$1.75
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3.25
|
|
|
SULFADOXINE + PYRIMETHAMINE TAB (500 MG-
|
Facility
OP
|
$7.00
|
|
| Hospital Charge Code |
41651311
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.45 |
| Max. Negotiated Rate |
$5.60 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$3.85
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3.50
|
| Rate for Payer: Aetna Government |
$3.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$5.60
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$4.76
|
| Rate for Payer: Group Health Inc Commercial |
$3.50
|
| Rate for Payer: Group Health Inc Medicare |
$2.45
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$3.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$3.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$4.55
|
|
|
SULFADOXINE + PYRIMETHAMINE TAB (500 MG-
|
Facility
OP
|
$7.00
|
|
| Hospital Charge Code |
41641311
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.45 |
| Max. Negotiated Rate |
$5.60 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$3.85
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3.50
|
| Rate for Payer: Aetna Government |
$3.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$5.60
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$4.76
|
| Rate for Payer: Group Health Inc Commercial |
$3.50
|
| Rate for Payer: Group Health Inc Medicare |
$2.45
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$3.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$3.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$4.55
|
|
|
SULFAMETHOXAZOLE/ TMP 0.8MG/MLD5W
|
Facility
OP
|
$0.75
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
41640270
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$0.49 |
| 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: Cigna HMO/Network Benefit Plan/Open Access |
$0.38
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.43
|
| 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
|
|
|
SULFAMETHOXAZOLE/ TMP 0.8MG/MLD5W
|
Facility
IP
|
$0.75
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
41650270
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$0.38 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.38
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.38
|
|
|
SULFAMETHOXAZOLE/ TMP 0.8MG/MLD5W
|
Facility
OP
|
$0.75
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
41650270
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$0.49 |
| 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: Cigna HMO/Network Benefit Plan/Open Access |
$0.38
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.43
|
| 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
|
|
|
SULFAMETHOXAZOLE/ TMP 0.8MG/MLD5W
|
Facility
IP
|
$0.75
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
41640270
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$0.38 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.38
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.38
|
|
|
SULFAMETHOXAZOLE-TMP 200 MG-40 MG/5 ML S
|
Facility
OP
|
$0.07
|
|
| Hospital Charge Code |
41645292
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.04
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.04
|
| Rate for Payer: Aetna Government |
$0.04
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.06
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.05
|
| Rate for Payer: Group Health Inc Commercial |
$0.04
|
| Rate for Payer: Group Health Inc Medicare |
$0.02
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.04
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.04
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.05
|
|
|
SULFAMETHOXAZOLE-TMP 200 MG-40 MG/5 ML S
|
Facility
OP
|
$0.07
|
|
| Hospital Charge Code |
41655292
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.04
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.04
|
| Rate for Payer: Aetna Government |
$0.04
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.06
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.05
|
| Rate for Payer: Group Health Inc Commercial |
$0.04
|
| Rate for Payer: Group Health Inc Medicare |
$0.02
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.04
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.04
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.05
|
|
|
SULFAMETHOXAZOLE-TMP 400 MG-80 MG SS TAB
|
Facility
OP
|
$0.18
|
|
| Hospital Charge Code |
41643404
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.10
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.09
|
| Rate for Payer: Aetna Government |
$0.09
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.14
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.12
|
| Rate for Payer: Group Health Inc Commercial |
$0.09
|
| Rate for Payer: Group Health Inc Medicare |
$0.06
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.09
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.09
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.12
|
|
|
SULFAMETHOXAZOLE-TMP 400 MG-80 MG SS TAB
|
Facility
OP
|
$0.18
|
|
| Hospital Charge Code |
41653404
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.10
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.09
|
| Rate for Payer: Aetna Government |
$0.09
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.14
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.12
|
| Rate for Payer: Group Health Inc Commercial |
$0.09
|
| Rate for Payer: Group Health Inc Medicare |
$0.06
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.09
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.09
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.12
|
|
|
SULFAMETHOXAZOLE-TMP 800 MG-160 MG DS TA
|
Facility
OP
|
$1.00
|
|
| Hospital Charge Code |
41653405
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$0.80 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.55
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.50
|
| Rate for Payer: Aetna Government |
$0.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.80
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.68
|
| Rate for Payer: Group Health Inc Commercial |
$0.50
|
| Rate for Payer: Group Health Inc Medicare |
$0.35
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.65
|
|
|
SULFAMETHOXAZOLE-TMP 800 MG-160 MG DS TA
|
Facility
OP
|
$1.00
|
|
| Hospital Charge Code |
41643405
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$0.80 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.55
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.50
|
| Rate for Payer: Aetna Government |
$0.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.80
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.68
|
| Rate for Payer: Group Health Inc Commercial |
$0.50
|
| Rate for Payer: Group Health Inc Medicare |
$0.35
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.65
|
|
|
SULFAMETHOXAZOLE-TMP 80 MG-16 MG/ML INJ
|
Facility
OP
|
$6.00
|
|
| Hospital Charge Code |
41640080
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.10 |
| Max. Negotiated Rate |
$4.80 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$3.30
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3.00
|
| Rate for Payer: Aetna Government |
$3.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$4.80
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$4.08
|
| Rate for Payer: Group Health Inc Commercial |
$3.00
|
| Rate for Payer: Group Health Inc Medicare |
$2.10
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$3.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$3.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3.90
|
|
|
SULFAMETHOXAZOLE-TMP 80 MG-16 MG/ML INJ
|
Facility
OP
|
$6.00
|
|
| Hospital Charge Code |
41650080
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.10 |
| Max. Negotiated Rate |
$4.80 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$3.30
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3.00
|
| Rate for Payer: Aetna Government |
$3.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$4.80
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$4.08
|
| Rate for Payer: Group Health Inc Commercial |
$3.00
|
| Rate for Payer: Group Health Inc Medicare |
$2.10
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$3.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$3.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3.90
|
|
|
SULFAMETH/TMP 800-160MG/20ML UD
|
Facility
OP
|
$5.14
|
|
| Hospital Charge Code |
41658029
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.80 |
| Max. Negotiated Rate |
$4.11 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2.83
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.57
|
| Rate for Payer: Aetna Government |
$2.57
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$4.11
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$3.50
|
| Rate for Payer: Group Health Inc Commercial |
$2.57
|
| Rate for Payer: Group Health Inc Medicare |
$1.80
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.57
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2.57
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3.34
|
|
|
SULFAMETH/TMP 800-160MG/20ML UD
|
Facility
OP
|
$5.14
|
|
| Hospital Charge Code |
41648029
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.80 |
| Max. Negotiated Rate |
$4.11 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2.83
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.57
|
| Rate for Payer: Aetna Government |
$2.57
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$4.11
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$3.50
|
| Rate for Payer: Group Health Inc Commercial |
$2.57
|
| Rate for Payer: Group Health Inc Medicare |
$1.80
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.57
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2.57
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3.34
|
|
|
SULFASALAZINE 500 MGTAB
|
Facility
OP
|
$0.31
|
|
| Hospital Charge Code |
41643974
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.25 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.17
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.16
|
| Rate for Payer: Aetna Government |
$0.16
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.25
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.21
|
| Rate for Payer: Group Health Inc Commercial |
$0.16
|
| Rate for Payer: Group Health Inc Medicare |
$0.11
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.16
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.16
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.20
|
|
|
SULFASALAZINE 500 MGTAB
|
Facility
OP
|
$0.31
|
|
| Hospital Charge Code |
41653974
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.25 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.17
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.16
|
| Rate for Payer: Aetna Government |
$0.16
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.25
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.21
|
| Rate for Payer: Group Health Inc Commercial |
$0.16
|
| Rate for Payer: Group Health Inc Medicare |
$0.11
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.16
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.16
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.20
|
|
