|
SP INTRA ARTERIAL CHEMO,INFUSION
|
Facility
|
IP
|
$556.18
|
|
|
Service Code
|
HCPCS 96422 TC
|
| Hospital Charge Code |
41561852
|
|
Hospital Revenue Code
|
335
|
| Rate for Payer: Cash Price |
$391.64
|
|
|
SP INTRACRAN ANGIOPLSTY W/STENT
|
Facility
|
OP
|
$9,552.85
|
|
|
Service Code
|
HCPCS 61635 TC
|
| Hospital Charge Code |
41543349
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1,496.00 |
| Max. Negotiated Rate |
$7,164.64 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$5,254.07
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,724.47
|
| Rate for Payer: Aetna Government |
$1,724.47
|
| Rate for Payer: Brighton Health Commercial |
$7,164.64
|
| 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: Group Health Inc Commercial |
$4,776.42
|
| Rate for Payer: Group Health Inc Medicare |
$3,343.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4,776.42
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4,776.42
|
| Rate for Payer: United Healthcare Commercial |
$1,496.00
|
|
|
SP INTRACRANIAL ANGIOPLASTY
|
Facility
|
OP
|
$9,062.15
|
|
|
Service Code
|
HCPCS 61630 TC
|
| Hospital Charge Code |
41543348
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1,496.00 |
| Max. Negotiated Rate |
$6,796.61 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$4,984.18
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,617.28
|
| Rate for Payer: Aetna Government |
$1,617.28
|
| Rate for Payer: Brighton Health Commercial |
$6,796.61
|
| 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: Group Health Inc Commercial |
$4,531.08
|
| Rate for Payer: Group Health Inc Medicare |
$3,171.75
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4,531.08
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4,531.08
|
| Rate for Payer: United Healthcare Commercial |
$1,496.00
|
|
|
SP INTR INTRAVAS STNT 1ST
|
Facility
|
IP
|
$30,948.00
|
|
|
Service Code
|
HCPCS 37236 TC
|
| Hospital Charge Code |
41104045
|
|
Hospital Revenue Code
|
361
|
| Rate for Payer: Cash Price |
$12,721.98
|
|
|
SP INTR INTRAVAS STNT 1ST
|
Facility
|
OP
|
$30,948.00
|
|
|
Service Code
|
HCPCS 37236 TC
|
| Hospital Charge Code |
41104045
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$2,477.75 |
| Max. Negotiated Rate |
$23,211.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$5,593.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$12,721.98
|
| Rate for Payer: Aetna Government |
$12,721.98
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$8,905.39
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$8,905.39
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$8,905.39
|
| Rate for Payer: Brighton Health Commercial |
$23,211.00
|
| Rate for Payer: Cash Price |
$12,721.98
|
| Rate for Payer: Cash Price |
$12,721.98
|
| Rate for Payer: Cash Price |
$12,721.98
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$12,721.98
|
| 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 |
$12,721.98
|
| Rate for Payer: EmblemHealth Commercial |
$12,721.98
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$10,813.68
|
| Rate for Payer: Fidelis Essential Plan QHP |
$11,322.56
|
| Rate for Payer: Fidelis Medicare Advantage |
$12,721.98
|
| Rate for Payer: Fidelis Qualified Health Plan |
$11,322.56
|
| Rate for Payer: Group Health Inc Commercial |
$12,721.98
|
| Rate for Payer: Group Health Inc Medicare |
$12,721.98
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$15,474.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$12,721.98
|
| Rate for Payer: Healthfirst Medicare Advantage |
$10,813.68
|
| Rate for Payer: Healthfirst QHP |
$12,721.98
|
| Rate for Payer: Humana Medicare |
$12,976.42
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$12,721.98
|
| Rate for Payer: United Healthcare Commercial |
$3,190.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12,721.98
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$12,721.98
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$10,177.58
|
| Rate for Payer: Wellcare Medicare |
$12,085.88
|
|
|
SP INTR INTRAVAS STNT ADD
|
Facility
|
OP
|
$15,474.00
|
|
|
Service Code
|
HCPCS 37237 TC
|
| Hospital Charge Code |
41104047
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$2,477.75 |
| Max. Negotiated Rate |
$11,605.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$5,593.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2,670.81
|
| Rate for Payer: Aetna Government |
$2,670.81
|
| Rate for Payer: Brighton Health Commercial |
$11,605.50
|
| 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: Group Health Inc Commercial |
$7,737.00
|
| Rate for Payer: Group Health Inc Medicare |
$5,415.90
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$7,737.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$7,737.00
|
| Rate for Payer: United Healthcare Commercial |
$2,546.00
|
|
|
SP INVUS NONCORONARY ADD VESSEL
|
Facility
|
OP
|
$1,520.83
|
|
|
Service Code
|
HCPCS 37253 TC
|
| Hospital Charge Code |
41561848
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$236.53 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,880.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$236.53
|
| Rate for Payer: Aetna Government |
$236.53
|
| Rate for Payer: Brighton Health Commercial |
$1,140.62
|
| 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: Group Health Inc Commercial |
$760.42
|
| Rate for Payer: Group Health Inc Medicare |
$532.29
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$760.42
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$760.42
|
| Rate for Payer: United Healthcare Commercial |
$1,113.00
|
|
|
SPIRATION VALVE SYSTEM
|
Facility
|
OP
|
$6,625.00
|
|
| Hospital Charge Code |
64906858
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$2,318.75 |
| Max. Negotiated Rate |
$5,300.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$3,643.75
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3,312.50
|
| Rate for Payer: Aetna Government |
$3,312.50
|
| Rate for Payer: Brighton Health Commercial |
$4,968.75
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$5,300.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$4,505.00
|
| Rate for Payer: Group Health Inc Commercial |
$3,312.50
|
| Rate for Payer: Group Health Inc Medicare |
$2,318.75
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$3,312.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$3,312.50
|
|
|
SPIRIVA INHALER QD
|
Facility
|
OP
|
$557.18
|
|
|
Service Code
|
HCPCS 94640
|
| Hospital Charge Code |
40306315
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$132.45 |
| Max. Negotiated Rate |
$417.88 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$306.45
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$246.65
|
| Rate for Payer: Aetna Government |
$246.65
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$172.66
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$172.66
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$172.66
|
| Rate for Payer: Brighton Health Commercial |
$417.88
|
| Rate for Payer: Cash Price |
$246.65
|
| Rate for Payer: Cash Price |
$246.65
|
| Rate for Payer: Cash Price |
$246.65
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$246.65
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$155.82
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$132.45
|
| Rate for Payer: Elderplan Medicare Advantage |
$246.65
|
| Rate for Payer: EmblemHealth Commercial |
$246.65
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$209.65
|
| Rate for Payer: Fidelis Essential Plan QHP |
$219.52
|
| Rate for Payer: Fidelis Medicare Advantage |
$246.65
|
| Rate for Payer: Fidelis Qualified Health Plan |
$219.52
|
| Rate for Payer: Group Health Inc Commercial |
$246.65
|
| Rate for Payer: Group Health Inc Medicare |
$246.65
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$278.59
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$246.65
|
| Rate for Payer: Healthfirst Medicare Advantage |
$209.65
|
| Rate for Payer: Healthfirst QHP |
$246.65
|
| Rate for Payer: Humana Medicare |
$251.58
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$246.65
|
| Rate for Payer: United Healthcare Commercial |
$278.59
|
| Rate for Payer: United Healthcare Medicare Advantage |
$246.65
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$246.65
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$197.32
|
| Rate for Payer: Wellcare Medicare |
$234.32
|
|
|
SPIRIVA INHALER QD
|
Facility
|
IP
|
$557.18
|
|
|
Service Code
|
HCPCS 94640
|
| Hospital Charge Code |
40306315
|
|
Hospital Revenue Code
|
410
|
| Rate for Payer: Cash Price |
$246.65
|
|
|
SPIROMETRY
|
Facility
|
IP
|
$419.03
|
|
|
Service Code
|
HCPCS 94010 TC
|
| Hospital Charge Code |
30305698
|
|
Hospital Revenue Code
|
460
|
| Rate for Payer: Cash Price |
$180.64
|
|
|
SPIROMETRY
|
Facility
|
OP
|
$419.03
|
|
|
Service Code
|
HCPCS 94010 TC
|
| Hospital Charge Code |
30305698
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$126.45 |
| Max. Negotiated Rate |
$335.22 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$230.47
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$180.64
|
| Rate for Payer: Aetna Government |
$180.64
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$126.45
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$126.45
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$126.45
|
| Rate for Payer: Brighton Health Commercial |
$314.27
|
| Rate for Payer: Cash Price |
$180.64
|
| Rate for Payer: Cash Price |
$180.64
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$180.64
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$335.22
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$284.94
|
| Rate for Payer: Elderplan Medicare Advantage |
$180.64
|
| Rate for Payer: EmblemHealth Commercial |
$180.64
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$153.54
|
| Rate for Payer: Fidelis Essential Plan QHP |
$160.77
|
| Rate for Payer: Fidelis Medicare Advantage |
$180.64
|
| Rate for Payer: Fidelis Qualified Health Plan |
$160.77
|
| Rate for Payer: Group Health Inc Commercial |
$180.64
|
| Rate for Payer: Group Health Inc Medicare |
$180.64
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$209.52
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$180.64
|
| Rate for Payer: Healthfirst Medicare Advantage |
$153.54
|
| Rate for Payer: Healthfirst QHP |
$180.64
|
| Rate for Payer: Humana Medicare |
$184.25
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$180.64
|
| Rate for Payer: United Healthcare Commercial |
$209.52
|
| Rate for Payer: United Healthcare Medicare Advantage |
$180.64
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$180.64
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$144.51
|
| Rate for Payer: Wellcare Medicare |
$171.61
|
|
|
SPIROMETRY
|
Facility
|
OP
|
$419.03
|
|
|
Service Code
|
HCPCS 94010 TC
|
| Hospital Charge Code |
40402704
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$126.45 |
| Max. Negotiated Rate |
$335.22 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$230.47
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$180.64
|
| Rate for Payer: Aetna Government |
$180.64
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$126.45
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$126.45
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$126.45
|
| Rate for Payer: Brighton Health Commercial |
$314.27
|
| Rate for Payer: Cash Price |
$180.64
|
| Rate for Payer: Cash Price |
$180.64
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$180.64
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$335.22
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$284.94
|
| Rate for Payer: Elderplan Medicare Advantage |
$180.64
|
| Rate for Payer: EmblemHealth Commercial |
$180.64
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$153.54
|
| Rate for Payer: Fidelis Essential Plan QHP |
$160.77
|
| Rate for Payer: Fidelis Medicare Advantage |
$180.64
|
| Rate for Payer: Fidelis Qualified Health Plan |
$160.77
|
| Rate for Payer: Group Health Inc Commercial |
$180.64
|
| Rate for Payer: Group Health Inc Medicare |
$180.64
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$209.52
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$180.64
|
| Rate for Payer: Healthfirst Medicare Advantage |
$153.54
|
| Rate for Payer: Healthfirst QHP |
$180.64
|
| Rate for Payer: Humana Medicare |
$184.25
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$180.64
|
| Rate for Payer: United Healthcare Commercial |
$209.52
|
| Rate for Payer: United Healthcare Medicare Advantage |
$180.64
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$180.64
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$144.51
|
| Rate for Payer: Wellcare Medicare |
$171.61
|
|
|
SPIROMETRY
|
Facility
|
IP
|
$419.03
|
|
|
Service Code
|
HCPCS 94010 TC
|
| Hospital Charge Code |
40402704
|
|
Hospital Revenue Code
|
460
|
| Rate for Payer: Cash Price |
$180.64
|
|
|
SPIRONOLACTONE 100 MG PO TABS [11425]
|
Facility
|
OP
|
$0.88
|
|
|
Service Code
|
NDC 60687048701
|
| Hospital Charge Code |
60687048701
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$0.70 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.48
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.44
|
| Rate for Payer: Aetna Government |
$0.44
|
| Rate for Payer: Brighton Health Commercial |
$0.66
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.70
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.60
|
| Rate for Payer: Group Health Inc Commercial |
$0.44
|
| Rate for Payer: Group Health Inc Medicare |
$0.31
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.44
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.44
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.57
|
|
|
SPIRONOLACTONE 100 MG PO TABS [11425]
|
Facility
|
OP
|
$0.88
|
|
|
Service Code
|
NDC 60687048711
|
| Hospital Charge Code |
60687048711
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$0.70 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.48
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.44
|
| Rate for Payer: Aetna Government |
$0.44
|
| Rate for Payer: Brighton Health Commercial |
$0.66
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.70
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.60
|
| Rate for Payer: Group Health Inc Commercial |
$0.44
|
| Rate for Payer: Group Health Inc Medicare |
$0.31
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.44
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.44
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.57
|
|
|
SPIRONOLACTONE 100 MG PO TABS [11425]
|
Facility
|
OP
|
$1.42
|
|
|
Service Code
|
NDC 53489032901
|
| Hospital Charge Code |
53489032901
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$1.13 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.78
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.71
|
| Rate for Payer: Aetna Government |
$0.71
|
| Rate for Payer: Brighton Health Commercial |
$1.06
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.13
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.96
|
| Rate for Payer: Group Health Inc Commercial |
$0.71
|
| Rate for Payer: Group Health Inc Medicare |
$0.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.71
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.71
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.92
|
|
|
SPIRONOLACTONE 100 MG TAB
|
Facility
|
OP
|
$2.00
|
|
| Hospital Charge Code |
41640653
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.70 |
| Max. Negotiated Rate |
$1.60 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.10
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.00
|
| Rate for Payer: Aetna Government |
$1.00
|
| Rate for Payer: Brighton Health Commercial |
$1.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.60
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.36
|
| Rate for Payer: Group Health Inc Commercial |
$1.00
|
| Rate for Payer: Group Health Inc Medicare |
$0.70
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.30
|
|
|
SPIRONOLACTONE 100 MG TAB
|
Facility
|
OP
|
$2.00
|
|
| Hospital Charge Code |
41650653
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.70 |
| Max. Negotiated Rate |
$1.60 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.10
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.00
|
| Rate for Payer: Aetna Government |
$1.00
|
| Rate for Payer: Brighton Health Commercial |
$1.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.60
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.36
|
| Rate for Payer: Group Health Inc Commercial |
$1.00
|
| Rate for Payer: Group Health Inc Medicare |
$0.70
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.30
|
|
|
SPIRONOLACTONE 1 MG/ML SUSP
|
Facility
|
OP
|
$1.00
|
|
| Hospital Charge Code |
41651814
|
|
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: Brighton Health Commercial |
$0.75
|
| 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
|
|
|
SPIRONOLACTONE 1 MG/ML SUSP
|
Facility
|
OP
|
$1.00
|
|
| Hospital Charge Code |
41641814
|
|
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: Brighton Health Commercial |
$0.75
|
| 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
|
|
|
SPIRONOLACTONE 25 MG PO TABS [7437]
|
Facility
|
OP
|
$0.43
|
|
|
Service Code
|
NDC 63739054410
|
| Hospital Charge Code |
63739054410
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.34 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.24
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.21
|
| Rate for Payer: Aetna Government |
$0.21
|
| Rate for Payer: Brighton Health Commercial |
$0.32
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.34
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.29
|
| Rate for Payer: Group Health Inc Commercial |
$0.21
|
| Rate for Payer: Group Health Inc Medicare |
$0.15
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.21
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.21
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.28
|
|
|
SPIRONOLACTONE 25 MG PO TABS [7437]
|
Facility
|
OP
|
$0.19
|
|
|
Service Code
|
NDC 00904692761
|
| Hospital Charge Code |
00904692761
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.15 |
| 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: Brighton Health Commercial |
$0.14
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.15
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.13
|
| Rate for Payer: Group Health Inc Commercial |
$0.09
|
| Rate for Payer: Group Health Inc Medicare |
$0.07
|
| 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
|
|
|
SPIRONOLACTONE 25 MG PO TABS [7437]
|
Facility
|
OP
|
$0.45
|
|
|
Service Code
|
NDC 16729022516
|
| Hospital Charge Code |
16729022516
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.36 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.25
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.22
|
| Rate for Payer: Aetna Government |
$0.22
|
| Rate for Payer: Brighton Health Commercial |
$0.34
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.36
|
| 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 |
$0.16
|
| 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
|
|
|
SPIRONOLACTONE 25 MG PO TABS [7437]
|
Facility
|
OP
|
$0.23
|
|
|
Service Code
|
NDC 60687046511
|
| Hospital Charge Code |
60687046511
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.13
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.11
|
| Rate for Payer: Aetna Government |
$0.11
|
| Rate for Payer: Brighton Health Commercial |
$0.17
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.18
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.16
|
| Rate for Payer: Group Health Inc Commercial |
$0.11
|
| Rate for Payer: Group Health Inc Medicare |
$0.08
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.11
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.11
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.15
|
|
