|
DILTIAZEM HCL ER COATED BEADS 120 MG PO CP24
|
Facility
|
IP
|
$1.22
|
|
|
Service Code
|
NDC 1037082911
|
| Hospital Charge Code |
1037082911
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$0.61 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.61
|
|
|
DILTIAZEM HCL ER COATED BEADS 120 MG PO CP24
|
Facility
|
OP
|
$0.54
|
|
|
Service Code
|
NDC 0904721761
|
| Hospital Charge Code |
0904721761
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.43 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.29
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.27
|
| Rate for Payer: Aetna Government |
$0.27
|
| Rate for Payer: Brighton Health Commercial |
$0.40
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.43
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.36
|
| Rate for Payer: EmblemHealth Commercial |
$0.27
|
| Rate for Payer: Group Health Inc Commercial |
$0.27
|
| Rate for Payer: Group Health Inc Medicare |
$0.19
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.27
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.27
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.35
|
|
|
DILTIAZEM HCL ER COATED BEADS 120 MG PO CP24
|
Facility
|
OP
|
$0.91
|
|
|
Service Code
|
NDC 2497902607
|
| Hospital Charge Code |
2497902607
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$0.72 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.45
|
| Rate for Payer: Aetna Government |
$0.45
|
| Rate for Payer: Brighton Health Commercial |
$0.68
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.72
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.62
|
| Rate for Payer: EmblemHealth Commercial |
$0.45
|
| Rate for Payer: Group Health Inc Commercial |
$0.45
|
| Rate for Payer: Group Health Inc Medicare |
$0.32
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.45
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.45
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.59
|
|
|
DILTIAZEM HCL ER COATED BEADS 120 MG PO CP24
|
Facility
|
OP
|
$0.97
|
|
|
Service Code
|
NDC 6068719501
|
| Hospital Charge Code |
6068719501
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$0.77 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.53
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.48
|
| Rate for Payer: Aetna Government |
$0.48
|
| Rate for Payer: Brighton Health Commercial |
$0.73
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.77
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.66
|
| Rate for Payer: EmblemHealth Commercial |
$0.48
|
| Rate for Payer: Group Health Inc Commercial |
$0.48
|
| Rate for Payer: Group Health Inc Medicare |
$0.34
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.48
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.48
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.63
|
|
|
DILTIAZEM HCL ER COATED BEADS 120 MG PO CP24
|
Facility
|
IP
|
$0.97
|
|
|
Service Code
|
NDC 6068719501
|
| Hospital Charge Code |
6068719501
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.48 |
| Max. Negotiated Rate |
$0.48 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.48
|
|
|
DILTIAZEM HCL ER COATED BEADS 120 MG PO CP24
|
Facility
|
IP
|
$0.54
|
|
|
Service Code
|
NDC 0904721761
|
| Hospital Charge Code |
0904721761
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$0.27 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.27
|
|
|
DILTIAZEM HCL ER COATED BEADS 120 MG PO CP24
|
Facility
|
OP
|
$1.22
|
|
|
Service Code
|
NDC 1037082911
|
| Hospital Charge Code |
1037082911
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$0.98 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.67
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.61
|
| Rate for Payer: Aetna Government |
$0.61
|
| Rate for Payer: Brighton Health Commercial |
$0.92
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.98
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.83
|
| Rate for Payer: EmblemHealth Commercial |
$0.61
|
| Rate for Payer: Group Health Inc Commercial |
$0.61
|
| Rate for Payer: Group Health Inc Medicare |
$0.43
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.61
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.61
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.79
|
|
|
DILTIAZEM HCL ER COATED BEADS 180 MG PO CP24
|
Facility
|
IP
|
$0.97
|
|
|
Service Code
|
NDC 6068720611
|
| Hospital Charge Code |
6068720611
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.49 |
| Max. Negotiated Rate |
$0.49 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.49
|
|
|
DILTIAZEM HCL ER COATED BEADS 180 MG PO CP24
|
Facility
|
OP
|
$1.16
|
|
|
Service Code
|
NDC 2497902706
|
| Hospital Charge Code |
2497902706
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.40 |
| Max. Negotiated Rate |
$0.92 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.64
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.58
|
| Rate for Payer: Aetna Government |
$0.58
|
| Rate for Payer: Brighton Health Commercial |
$0.87
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.92
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.79
|
| Rate for Payer: EmblemHealth Commercial |
$0.58
|
| Rate for Payer: Group Health Inc Commercial |
$0.58
|
| Rate for Payer: Group Health Inc Medicare |
$0.40
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.58
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.58
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.75
|
|
|
DILTIAZEM HCL ER COATED BEADS 180 MG PO CP24
|
Facility
|
IP
|
$1.51
|
|
|
Service Code
|
NDC 1037083011
|
| Hospital Charge Code |
1037083011
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.76 |
| Max. Negotiated Rate |
$0.76 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.76
|
|
|
DILTIAZEM HCL ER COATED BEADS 180 MG PO CP24
|
Facility
|
OP
|
$0.97
|
|
|
Service Code
|
NDC 6068720611
|
| Hospital Charge Code |
6068720611
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$0.78 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.53
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.49
|
| Rate for Payer: Aetna Government |
$0.49
|
| Rate for Payer: Brighton Health Commercial |
$0.73
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.78
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.66
|
| Rate for Payer: EmblemHealth Commercial |
$0.49
|
| 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 |
$0.63
|
|
|
DILTIAZEM HCL ER COATED BEADS 180 MG PO CP24
|
Facility
|
OP
|
$1.51
|
|
|
Service Code
|
NDC 1037083011
|
| Hospital Charge Code |
1037083011
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.53 |
| Max. Negotiated Rate |
$1.21 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.83
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.76
|
| Rate for Payer: Aetna Government |
$0.76
|
| Rate for Payer: Brighton Health Commercial |
$1.13
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.21
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.03
|
| Rate for Payer: EmblemHealth Commercial |
$0.76
|
| Rate for Payer: Group Health Inc Commercial |
$0.76
|
| Rate for Payer: Group Health Inc Medicare |
$0.53
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.76
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.76
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.98
|
|
|
DILTIAZEM HCL ER COATED BEADS 180 MG PO CP24
|
Facility
|
IP
|
$1.16
|
|
|
Service Code
|
NDC 2497902706
|
| Hospital Charge Code |
2497902706
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$0.58 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.58
|
|
|
DILTIAZEM HCL ER COATED BEADS 180 MG PO CP24
|
Facility
|
IP
|
$0.97
|
|
|
Service Code
|
NDC 6068720601
|
| Hospital Charge Code |
6068720601
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.48 |
| Max. Negotiated Rate |
$0.48 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.48
|
|
|
DILTIAZEM HCL ER COATED BEADS 180 MG PO CP24
|
Facility
|
OP
|
$0.97
|
|
|
Service Code
|
NDC 6068720601
|
| Hospital Charge Code |
6068720601
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$0.77 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.53
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.48
|
| Rate for Payer: Aetna Government |
$0.48
|
| Rate for Payer: Brighton Health Commercial |
$0.73
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.77
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.66
|
| Rate for Payer: EmblemHealth Commercial |
$0.48
|
| Rate for Payer: Group Health Inc Commercial |
$0.48
|
| Rate for Payer: Group Health Inc Medicare |
$0.34
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.48
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.48
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.63
|
|
|
DILTIAZEM HCL ER COATED BEADS 240 MG PO CP24
|
Facility
|
OP
|
$0.80
|
|
|
Service Code
|
NDC 6068721701
|
| Hospital Charge Code |
6068721701
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$0.64 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.44
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.40
|
| Rate for Payer: Aetna Government |
$0.40
|
| Rate for Payer: Brighton Health Commercial |
$0.60
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.64
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.55
|
| Rate for Payer: EmblemHealth Commercial |
$0.40
|
| Rate for Payer: Group Health Inc Commercial |
$0.40
|
| Rate for Payer: Group Health Inc Medicare |
$0.28
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.40
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.40
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.52
|
|
|
DILTIAZEM HCL ER COATED BEADS 240 MG PO CP24
|
Facility
|
IP
|
$0.80
|
|
|
Service Code
|
NDC 6068721701
|
| Hospital Charge Code |
6068721701
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.40 |
| Max. Negotiated Rate |
$0.40 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.40
|
|
|
DILTIAZEM HCL ER COATED BEADS 300 MG PO CP24
|
Facility
|
IP
|
$2.12
|
|
|
Service Code
|
NDC 2497902906
|
| Hospital Charge Code |
2497902906
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.06 |
| Max. Negotiated Rate |
$1.06 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.06
|
|
|
DILTIAZEM HCL ER COATED BEADS 300 MG PO CP24
|
Facility
|
OP
|
$2.12
|
|
|
Service Code
|
NDC 2497902906
|
| Hospital Charge Code |
2497902906
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.74 |
| Max. Negotiated Rate |
$1.70 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.17
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.06
|
| Rate for Payer: Aetna Government |
$1.06
|
| Rate for Payer: Brighton Health Commercial |
$1.59
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.70
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.44
|
| Rate for Payer: EmblemHealth Commercial |
$1.06
|
| Rate for Payer: Group Health Inc Commercial |
$1.06
|
| Rate for Payer: Group Health Inc Medicare |
$0.74
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.06
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.06
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.38
|
|
|
DIMENHYDRINATE 50 MG PO TABS
|
Facility
|
OP
|
$0.05
|
|
|
Service Code
|
NDC 0904205159
|
| Hospital Charge Code |
0904205159
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.03
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.03
|
| Rate for Payer: Aetna Government |
$0.03
|
| Rate for Payer: Brighton Health Commercial |
$0.04
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.04
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.04
|
| Rate for Payer: EmblemHealth Commercial |
$0.03
|
| Rate for Payer: Group Health Inc Commercial |
$0.03
|
| Rate for Payer: Group Health Inc Medicare |
$0.02
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.03
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.03
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.03
|
|
|
DIMENHYDRINATE 50 MG PO TABS
|
Facility
|
IP
|
$0.05
|
|
|
Service Code
|
NDC 0904205159
|
| Hospital Charge Code |
0904205159
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.03
|
|
|
DIMETHYL SULFOXIDE 50 % IS SOLN
|
Facility
|
OP
|
$16.68
|
|
|
Service Code
|
HCPCS J1212
|
| Hospital Charge Code |
6745717750
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.17 |
| Max. Negotiated Rate |
$763.83 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$9.17
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$748.85
|
| Rate for Payer: Aetna Government |
$748.85
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$524.20
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$524.20
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$524.20
|
| Rate for Payer: Brighton Health Commercial |
$12.51
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$748.85
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$13.34
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$11.34
|
| Rate for Payer: Elderplan Medicare Advantage |
$748.85
|
| Rate for Payer: EmblemHealth Commercial |
$748.85
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$673.97
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$636.52
|
| Rate for Payer: Fidelis Essential Plan QHP |
$666.48
|
| Rate for Payer: Fidelis Medicare Advantage |
$748.85
|
| Rate for Payer: Fidelis Qualified Health Plan |
$666.48
|
| Rate for Payer: Group Health Inc Commercial |
$748.85
|
| Rate for Payer: Group Health Inc Medicare |
$748.85
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$748.85
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$748.85
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$748.85
|
| Rate for Payer: Healthfirst Medicare Advantage |
$636.52
|
| Rate for Payer: Healthfirst QHP |
$748.85
|
| Rate for Payer: Humana Medicare |
$763.83
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$748.85
|
| Rate for Payer: United Healthcare Medicare Advantage |
$748.85
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$10.84
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$711.41
|
| Rate for Payer: Wellcare Medicare |
$711.41
|
|
|
DIMETHYL SULFOXIDE 50 % IS SOLN
|
Facility
|
IP
|
$16.68
|
|
|
Service Code
|
HCPCS J1212
|
| Hospital Charge Code |
6745717750
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.34 |
| Max. Negotiated Rate |
$8.34 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$8.34
|
|
|
DINOPROSTONE 10 MG VA INST
|
Facility
|
OP
|
$628.78
|
|
|
Service Code
|
NDC 5556628001
|
| Hospital Charge Code |
5556628001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$220.07 |
| Max. Negotiated Rate |
$503.02 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$345.83
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$314.39
|
| Rate for Payer: Aetna Government |
$314.39
|
| Rate for Payer: Brighton Health Commercial |
$471.58
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$503.02
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$427.57
|
| Rate for Payer: EmblemHealth Commercial |
$314.39
|
| Rate for Payer: Group Health Inc Commercial |
$314.39
|
| Rate for Payer: Group Health Inc Medicare |
$220.07
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$314.39
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$314.39
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$408.71
|
|
|
DINOPROSTONE 10 MG VA INST
|
Facility
|
IP
|
$628.78
|
|
|
Service Code
|
NDC 5556628001
|
| Hospital Charge Code |
5556628001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$314.39 |
| Max. Negotiated Rate |
$314.39 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$314.39
|
|
