|
TGAB+THYROGLOBULIN,IMA OR RIA
|
Facility
|
OP
|
$39.78
|
|
|
Service Code
|
HCPCS 86800
|
| Hospital Charge Code |
40609151
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.14 |
| Max. Negotiated Rate |
$29.84 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$21.88
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$15.91
|
| Rate for Payer: Aetna Government |
$15.91
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$11.14
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$11.14
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$11.14
|
| Rate for Payer: Brighton Health Commercial |
$29.84
|
| Rate for Payer: Cash Price |
$15.91
|
| Rate for Payer: Cash Price |
$15.91
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$15.91
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$25.28
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$21.40
|
| Rate for Payer: Elderplan Medicare Advantage |
$15.91
|
| Rate for Payer: EmblemHealth Commercial |
$15.91
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$13.52
|
| Rate for Payer: Fidelis Essential Plan QHP |
$14.16
|
| Rate for Payer: Fidelis Medicare Advantage |
$15.91
|
| Rate for Payer: Fidelis Qualified Health Plan |
$14.16
|
| Rate for Payer: Group Health Inc Commercial |
$15.91
|
| Rate for Payer: Group Health Inc Medicare |
$15.91
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$19.89
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$15.91
|
| Rate for Payer: Healthfirst Medicare Advantage |
$15.91
|
| Rate for Payer: Healthfirst QHP |
$15.91
|
| Rate for Payer: Humana Medicare |
$16.23
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$15.91
|
| Rate for Payer: United Healthcare Commercial |
$20.14
|
| Rate for Payer: United Healthcare Medicare Advantage |
$15.91
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$15.91
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$12.73
|
| Rate for Payer: Wellcare Medicare |
$14.32
|
|
|
THALLIUM TL-201
|
Facility
|
OP
|
$9.43
|
|
|
Service Code
|
HCPCS A9505
|
| Hospital Charge Code |
41656488
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$3.30 |
| Max. Negotiated Rate |
$126.19 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$5.19
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$126.19
|
| Rate for Payer: Aetna Government |
$126.19
|
| Rate for Payer: Brighton Health Commercial |
$7.07
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$7.54
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$6.41
|
| Rate for Payer: Group Health Inc Commercial |
$4.72
|
| Rate for Payer: Group Health Inc Medicare |
$3.30
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4.72
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4.72
|
|
|
THALLIUM TL-201
|
Facility
|
OP
|
$9.43
|
|
|
Service Code
|
HCPCS A9505
|
| Hospital Charge Code |
41646488
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$3.30 |
| Max. Negotiated Rate |
$126.19 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$5.19
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$126.19
|
| Rate for Payer: Aetna Government |
$126.19
|
| Rate for Payer: Brighton Health Commercial |
$7.07
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$7.54
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$6.41
|
| Rate for Payer: Group Health Inc Commercial |
$4.72
|
| Rate for Payer: Group Health Inc Medicare |
$3.30
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4.72
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4.72
|
|
|
THC-U
|
Facility
|
OP
|
$155.35
|
|
|
Service Code
|
HCPCS 80361
|
| Hospital Charge Code |
40602450
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$124.28 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$85.44
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.01
|
| Rate for Payer: Aetna Government |
$0.01
|
| Rate for Payer: Brighton Health Commercial |
$116.51
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$124.28
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$105.64
|
| Rate for Payer: Group Health Inc Commercial |
$77.68
|
| Rate for Payer: Group Health Inc Medicare |
$54.37
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$77.68
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$77.68
|
| Rate for Payer: United Healthcare Commercial |
$31.48
|
|
|
THEOPHYLLIN
|
Facility
|
OP
|
$35.35
|
|
|
Service Code
|
HCPCS 80198
|
| Hospital Charge Code |
40602000
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$9.90 |
| Max. Negotiated Rate |
$26.51 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$19.44
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$14.14
|
| Rate for Payer: Aetna Government |
$14.14
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$9.90
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$9.90
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$9.90
|
| Rate for Payer: Brighton Health Commercial |
$26.51
|
| Rate for Payer: Cash Price |
$14.14
|
| Rate for Payer: Cash Price |
$14.14
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$14.14
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$22.49
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$19.03
|
| Rate for Payer: Elderplan Medicare Advantage |
$14.14
|
| Rate for Payer: EmblemHealth Commercial |
$14.14
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$12.02
|
| Rate for Payer: Fidelis Essential Plan QHP |
$12.58
|
| Rate for Payer: Fidelis Medicare Advantage |
$14.14
|
| Rate for Payer: Fidelis Qualified Health Plan |
$12.58
|
| Rate for Payer: Group Health Inc Commercial |
$14.14
|
| Rate for Payer: Group Health Inc Medicare |
$14.14
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$17.68
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$14.14
|
| Rate for Payer: Healthfirst Medicare Advantage |
$14.14
|
| Rate for Payer: Healthfirst QHP |
$14.14
|
| Rate for Payer: Humana Medicare |
$14.42
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$14.14
|
| Rate for Payer: United Healthcare Commercial |
$17.92
|
| Rate for Payer: United Healthcare Medicare Advantage |
$14.14
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$14.14
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$11.31
|
| Rate for Payer: Wellcare Medicare |
$12.73
|
|
|
THEOPHYLLIN
|
Facility
|
IP
|
$35.35
|
|
|
Service Code
|
HCPCS 80198
|
| Hospital Charge Code |
40602000
|
|
Hospital Revenue Code
|
301
|
| Rate for Payer: Cash Price |
$14.14
|
|
|
THEOPHYLLINE 100 MG TAB CR
|
Facility
|
OP
|
$0.25
|
|
| Hospital Charge Code |
41643919
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.14
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.13
|
| Rate for Payer: Aetna Government |
$0.13
|
| Rate for Payer: Brighton Health Commercial |
$0.19
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.20
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.17
|
| Rate for Payer: Group Health Inc Commercial |
$0.13
|
| Rate for Payer: Group Health Inc Medicare |
$0.09
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.13
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.13
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.16
|
|
|
THEOPHYLLINE 100 MG TAB CR
|
Facility
|
OP
|
$0.25
|
|
| Hospital Charge Code |
41653919
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.14
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.13
|
| Rate for Payer: Aetna Government |
$0.13
|
| Rate for Payer: Brighton Health Commercial |
$0.19
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.20
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.17
|
| Rate for Payer: Group Health Inc Commercial |
$0.13
|
| Rate for Payer: Group Health Inc Medicare |
$0.09
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.13
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.13
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.16
|
|
|
THEOPHYLLINE 125 MG CAP ER
|
Facility
|
OP
|
$1.00
|
|
| Hospital Charge Code |
41652821
|
|
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
|
|
|
THEOPHYLLINE 125 MG CAP ER
|
Facility
|
OP
|
$1.00
|
|
| Hospital Charge Code |
41642821
|
|
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
|
|
|
THEOPHYLLINE 200 MG TAB CR
|
Facility
|
OP
|
$0.33
|
|
| Hospital Charge Code |
41652286
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.18
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.17
|
| Rate for Payer: Aetna Government |
$0.17
|
| Rate for Payer: Brighton Health Commercial |
$0.25
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.26
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.22
|
| Rate for Payer: Group Health Inc Commercial |
$0.17
|
| Rate for Payer: Group Health Inc Medicare |
$0.12
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.17
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.17
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.21
|
|
|
THEOPHYLLINE 200 MG TAB CR
|
Facility
|
OP
|
$0.33
|
|
| Hospital Charge Code |
41642286
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.18
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.17
|
| Rate for Payer: Aetna Government |
$0.17
|
| Rate for Payer: Brighton Health Commercial |
$0.25
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.26
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.22
|
| Rate for Payer: Group Health Inc Commercial |
$0.17
|
| Rate for Payer: Group Health Inc Medicare |
$0.12
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.17
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.17
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.21
|
|
|
THEOPHYLLINE 300 MG TAB CR
|
Facility
|
OP
|
$1.00
|
|
| Hospital Charge Code |
41652287
|
|
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
|
|
|
THEOPHYLLINE 300 MG TAB CR
|
Facility
|
OP
|
$1.00
|
|
| Hospital Charge Code |
41642287
|
|
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
|
|
|
THEOPHYLLINE 80MG/15ML ELIXIR
|
Facility
|
OP
|
$18.54
|
|
| Hospital Charge Code |
41653644
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.49 |
| Max. Negotiated Rate |
$14.83 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$10.20
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$9.27
|
| Rate for Payer: Aetna Government |
$9.27
|
| Rate for Payer: Brighton Health Commercial |
$13.90
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$14.83
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$12.61
|
| Rate for Payer: Group Health Inc Commercial |
$9.27
|
| Rate for Payer: Group Health Inc Medicare |
$6.49
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$9.27
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$9.27
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$12.05
|
|
|
THEOPHYLLINE 80MG/15ML ELIXIR
|
Facility
|
OP
|
$18.54
|
|
| Hospital Charge Code |
41643644
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.49 |
| Max. Negotiated Rate |
$14.83 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$10.20
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$9.27
|
| Rate for Payer: Aetna Government |
$9.27
|
| Rate for Payer: Brighton Health Commercial |
$13.90
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$14.83
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$12.61
|
| Rate for Payer: Group Health Inc Commercial |
$9.27
|
| Rate for Payer: Group Health Inc Medicare |
$6.49
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$9.27
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$9.27
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$12.05
|
|
|
THEOPHYLLINE 80 MG/15ML PO ELIX [7820]
|
Facility
|
OP
|
$0.33
|
|
|
Service Code
|
NDC 17856064401
|
| Hospital Charge Code |
17856064401
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.18
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.16
|
| Rate for Payer: Aetna Government |
$0.16
|
| Rate for Payer: Brighton Health Commercial |
$0.25
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.26
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.22
|
| 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 |
$0.21
|
|
|
THEOPHYLLINE 80 MG/15ML PO ELIX [7820]
|
Facility
|
OP
|
$0.84
|
|
|
Service Code
|
NDC 00121482015
|
| Hospital Charge Code |
00121482015
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$0.67 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.46
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.42
|
| Rate for Payer: Aetna Government |
$0.42
|
| Rate for Payer: Brighton Health Commercial |
$0.63
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.67
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.57
|
| Rate for Payer: Group Health Inc Commercial |
$0.42
|
| Rate for Payer: Group Health Inc Medicare |
$0.29
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.42
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.42
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.54
|
|
|
THEOPHYLLINE ER 100MG CAP
|
Facility
|
OP
|
$3.73
|
|
| Hospital Charge Code |
41646620
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.31 |
| Max. Negotiated Rate |
$2.98 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2.05
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.86
|
| Rate for Payer: Aetna Government |
$1.86
|
| Rate for Payer: Brighton Health Commercial |
$2.80
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2.98
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2.54
|
| Rate for Payer: Group Health Inc Commercial |
$1.86
|
| Rate for Payer: Group Health Inc Medicare |
$1.31
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.86
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.86
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2.42
|
|
|
THEOPHYLLINE ER 100MG CAP
|
Facility
|
OP
|
$3.73
|
|
| Hospital Charge Code |
41656620
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.31 |
| Max. Negotiated Rate |
$2.98 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2.05
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.86
|
| Rate for Payer: Aetna Government |
$1.86
|
| Rate for Payer: Brighton Health Commercial |
$2.80
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2.98
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2.54
|
| Rate for Payer: Group Health Inc Commercial |
$1.86
|
| Rate for Payer: Group Health Inc Medicare |
$1.31
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.86
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.86
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2.42
|
|
|
THEOPHYLLINE ER 100 MG PO CP24 [27418]
|
Facility
|
OP
|
$4.23
|
|
|
Service Code
|
NDC 52244010010
|
| Hospital Charge Code |
52244010010
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.48 |
| Max. Negotiated Rate |
$3.38 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2.32
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.11
|
| Rate for Payer: Aetna Government |
$2.11
|
| Rate for Payer: Brighton Health Commercial |
$3.17
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$3.38
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2.87
|
| Rate for Payer: Group Health Inc Commercial |
$2.11
|
| Rate for Payer: Group Health Inc Medicare |
$1.48
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.11
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2.11
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2.75
|
|
|
THEOPHYLLINE ER 200MG CAP
|
Facility
|
OP
|
$5.55
|
|
| Hospital Charge Code |
41656621
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.94 |
| Max. Negotiated Rate |
$4.44 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$3.05
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.78
|
| Rate for Payer: Aetna Government |
$2.78
|
| Rate for Payer: Brighton Health Commercial |
$4.16
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$4.44
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$3.77
|
| Rate for Payer: Group Health Inc Commercial |
$2.78
|
| Rate for Payer: Group Health Inc Medicare |
$1.94
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.78
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2.78
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3.61
|
|
|
THEOPHYLLINE ER 200MG CAP
|
Facility
|
OP
|
$5.55
|
|
| Hospital Charge Code |
41646621
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.94 |
| Max. Negotiated Rate |
$4.44 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$3.05
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.78
|
| Rate for Payer: Aetna Government |
$2.78
|
| Rate for Payer: Brighton Health Commercial |
$4.16
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$4.44
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$3.77
|
| Rate for Payer: Group Health Inc Commercial |
$2.78
|
| Rate for Payer: Group Health Inc Medicare |
$1.94
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.78
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2.78
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3.61
|
|
|
THEOPHYLLINE ER 200 MG PO CP24 [27419]
|
Facility
|
OP
|
$6.28
|
|
|
Service Code
|
NDC 52244020010
|
| Hospital Charge Code |
52244020010
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.20 |
| Max. Negotiated Rate |
$5.02 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$3.45
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3.14
|
| Rate for Payer: Aetna Government |
$3.14
|
| Rate for Payer: Brighton Health Commercial |
$4.71
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$5.02
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$4.27
|
| Rate for Payer: Group Health Inc Commercial |
$3.14
|
| Rate for Payer: Group Health Inc Medicare |
$2.20
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$3.14
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$3.14
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$4.08
|
|
|
THEOPHYLLINE ER 300MG CAP
|
Facility
|
OP
|
$6.83
|
|
| Hospital Charge Code |
41646622
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.39 |
| Max. Negotiated Rate |
$5.46 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$3.76
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3.42
|
| Rate for Payer: Aetna Government |
$3.42
|
| Rate for Payer: Brighton Health Commercial |
$5.12
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$5.46
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$4.64
|
| Rate for Payer: Group Health Inc Commercial |
$3.42
|
| Rate for Payer: Group Health Inc Medicare |
$2.39
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$3.42
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$3.42
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$4.44
|
|
