|
AMIODARONE HCL IN DEXTROSE 360-4.14 MG/200ML-% IV SOLN
|
Facility
|
IP
|
$0.28
|
|
|
Service Code
|
NDC 4306636020
|
| Hospital Charge Code |
4306636020
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.14
|
|
|
AMIODARONE HCL IN DEXTROSE 360-4.14 MG/200ML-% IV SOLN
|
Facility
|
OP
|
$0.28
|
|
|
Service Code
|
NDC 4306636020
|
| Hospital Charge Code |
4306636020
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.15
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.14
|
| Rate for Payer: Aetna Government |
$0.14
|
| Rate for Payer: Brighton Health Commercial |
$0.21
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.22
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.19
|
| Rate for Payer: EmblemHealth Commercial |
$0.14
|
| Rate for Payer: Group Health Inc Commercial |
$0.14
|
| Rate for Payer: Group Health Inc Medicare |
$0.10
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.14
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.14
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.18
|
|
|
AMITRIPTYLINE HCL 10 MG PO TABS
|
Facility
|
OP
|
$0.32
|
|
|
Service Code
|
NDC 1672917101
|
| Hospital Charge Code |
1672917101
|
|
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: Brighton Health Commercial |
$0.24
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.25
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.22
|
| Rate for Payer: EmblemHealth Commercial |
$0.16
|
| 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
|
|
|
AMITRIPTYLINE HCL 10 MG PO TABS
|
Facility
|
IP
|
$0.50
|
|
|
Service Code
|
NDC 5026803715
|
| Hospital Charge Code |
5026803715
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$0.25 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.25
|
|
|
AMITRIPTYLINE HCL 10 MG PO TABS
|
Facility
|
IP
|
$0.32
|
|
|
Service Code
|
NDC 1672917101
|
| Hospital Charge Code |
1672917101
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.16
|
|
|
AMITRIPTYLINE HCL 10 MG PO TABS
|
Facility
|
OP
|
$0.50
|
|
|
Service Code
|
NDC 5026803711
|
| Hospital Charge Code |
5026803711
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.40 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.27
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.25
|
| Rate for Payer: Aetna Government |
$0.25
|
| Rate for Payer: Brighton Health Commercial |
$0.37
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.40
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.34
|
| Rate for Payer: EmblemHealth Commercial |
$0.25
|
| Rate for Payer: Group Health Inc Commercial |
$0.25
|
| Rate for Payer: Group Health Inc Medicare |
$0.17
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.25
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.25
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.32
|
|
|
AMITRIPTYLINE HCL 10 MG PO TABS
|
Facility
|
OP
|
$0.50
|
|
|
Service Code
|
NDC 5026803715
|
| Hospital Charge Code |
5026803715
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.40 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.27
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.25
|
| Rate for Payer: Aetna Government |
$0.25
|
| Rate for Payer: Brighton Health Commercial |
$0.37
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.40
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.34
|
| Rate for Payer: EmblemHealth Commercial |
$0.25
|
| Rate for Payer: Group Health Inc Commercial |
$0.25
|
| Rate for Payer: Group Health Inc Medicare |
$0.17
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.25
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.25
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.32
|
|
|
AMITRIPTYLINE HCL 10 MG PO TABS
|
Facility
|
IP
|
$0.50
|
|
|
Service Code
|
NDC 5026803711
|
| Hospital Charge Code |
5026803711
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$0.25 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.25
|
|
|
AMITRIPTYLINE HCL 25 MG PO TABS
|
Facility
|
IP
|
$2.98
|
|
|
Service Code
|
NDC 0904741061
|
| Hospital Charge Code |
0904741061
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.49 |
| Max. Negotiated Rate |
$1.49 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.49
|
|
|
AMITRIPTYLINE HCL 25 MG PO TABS
|
Facility
|
OP
|
$0.64
|
|
|
Service Code
|
NDC 0904020161
|
| Hospital Charge Code |
0904020161
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$0.51 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.35
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.32
|
| Rate for Payer: Aetna Government |
$0.32
|
| Rate for Payer: Brighton Health Commercial |
$0.48
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.51
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.43
|
| Rate for Payer: EmblemHealth Commercial |
$0.32
|
| Rate for Payer: Group Health Inc Commercial |
$0.32
|
| Rate for Payer: Group Health Inc Medicare |
$0.22
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.32
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.32
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.41
|
|
|
AMITRIPTYLINE HCL 25 MG PO TABS
|
Facility
|
OP
|
$0.64
|
|
|
Service Code
|
NDC 7071012261
|
| Hospital Charge Code |
7071012261
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$0.51 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.35
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.32
|
| Rate for Payer: Aetna Government |
$0.32
|
| Rate for Payer: Brighton Health Commercial |
$0.48
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.51
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.43
|
| Rate for Payer: EmblemHealth Commercial |
$0.32
|
| Rate for Payer: Group Health Inc Commercial |
$0.32
|
| Rate for Payer: Group Health Inc Medicare |
$0.22
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.32
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.32
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.41
|
|
|
AMITRIPTYLINE HCL 25 MG PO TABS
|
Facility
|
OP
|
$2.98
|
|
|
Service Code
|
NDC 0904741061
|
| Hospital Charge Code |
0904741061
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.04 |
| Max. Negotiated Rate |
$2.38 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.64
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.49
|
| Rate for Payer: Aetna Government |
$1.49
|
| Rate for Payer: Brighton Health Commercial |
$2.23
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2.38
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2.03
|
| Rate for Payer: EmblemHealth Commercial |
$1.49
|
| Rate for Payer: Group Health Inc Commercial |
$1.49
|
| Rate for Payer: Group Health Inc Medicare |
$1.04
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.49
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.49
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.94
|
|
|
AMITRIPTYLINE HCL 25 MG PO TABS
|
Facility
|
IP
|
$0.64
|
|
|
Service Code
|
NDC 7071012261
|
| Hospital Charge Code |
7071012261
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.32
|
|
|
AMITRIPTYLINE HCL 25 MG PO TABS
|
Facility
|
IP
|
$0.64
|
|
|
Service Code
|
NDC 0904020161
|
| Hospital Charge Code |
0904020161
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.32
|
|
|
AMITRIPTYLINE HCL 25 MG PO TABS
|
Facility
|
IP
|
$0.52
|
|
|
Service Code
|
NDC 6068743311
|
| Hospital Charge Code |
6068743311
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.26
|
|
|
AMITRIPTYLINE HCL 25 MG PO TABS
|
Facility
|
OP
|
$0.52
|
|
|
Service Code
|
NDC 6068743311
|
| Hospital Charge Code |
6068743311
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.41 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.28
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.26
|
| Rate for Payer: Aetna Government |
$0.26
|
| Rate for Payer: Brighton Health Commercial |
$0.39
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.41
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.35
|
| Rate for Payer: EmblemHealth Commercial |
$0.26
|
| Rate for Payer: Group Health Inc Commercial |
$0.26
|
| Rate for Payer: Group Health Inc Medicare |
$0.18
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.26
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.26
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.34
|
|
|
AMITRIPTYLINE HCL 50 MG PO TABS
|
Facility
|
IP
|
$0.38
|
|
|
Service Code
|
NDC 0904741161
|
| Hospital Charge Code |
0904741161
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.19 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.19
|
|
|
AMITRIPTYLINE HCL 50 MG PO TABS
|
Facility
|
IP
|
$1.27
|
|
|
Service Code
|
NDC 7071012271
|
| Hospital Charge Code |
7071012271
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.64 |
| Max. Negotiated Rate |
$0.64 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.64
|
|
|
AMITRIPTYLINE HCL 50 MG PO TABS
|
Facility
|
OP
|
$0.38
|
|
|
Service Code
|
NDC 0904741161
|
| Hospital Charge Code |
0904741161
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.30 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.21
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.19
|
| Rate for Payer: Aetna Government |
$0.19
|
| Rate for Payer: Brighton Health Commercial |
$0.29
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.30
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.26
|
| Rate for Payer: EmblemHealth Commercial |
$0.19
|
| Rate for Payer: Group Health Inc Commercial |
$0.19
|
| Rate for Payer: Group Health Inc Medicare |
$0.13
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.19
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.19
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.25
|
|
|
AMITRIPTYLINE HCL 50 MG PO TABS
|
Facility
|
OP
|
$1.27
|
|
|
Service Code
|
NDC 7071012271
|
| Hospital Charge Code |
7071012271
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.44 |
| Max. Negotiated Rate |
$1.02 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.70
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.64
|
| Rate for Payer: Aetna Government |
$0.64
|
| Rate for Payer: Brighton Health Commercial |
$0.95
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.02
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.86
|
| Rate for Payer: EmblemHealth Commercial |
$0.64
|
| Rate for Payer: Group Health Inc Commercial |
$0.64
|
| Rate for Payer: Group Health Inc Medicare |
$0.44
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.64
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.64
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.83
|
|
|
AMLODIPINE BENZOATE 1 MG/ML PO SUSP
|
Facility
|
IP
|
$4.70
|
|
|
Service Code
|
NDC 5265250011
|
| Hospital Charge Code |
5265250011
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.35 |
| Max. Negotiated Rate |
$2.35 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.35
|
|
|
AMLODIPINE BENZOATE 1 MG/ML PO SUSP
|
Facility
|
OP
|
$4.70
|
|
|
Service Code
|
NDC 5265250011
|
| Hospital Charge Code |
5265250011
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.64 |
| Max. Negotiated Rate |
$3.76 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2.58
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.35
|
| Rate for Payer: Aetna Government |
$2.35
|
| Rate for Payer: Brighton Health Commercial |
$3.52
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$3.76
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$3.19
|
| Rate for Payer: EmblemHealth Commercial |
$2.35
|
| Rate for Payer: Group Health Inc Commercial |
$2.35
|
| Rate for Payer: Group Health Inc Medicare |
$1.64
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.35
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2.35
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3.05
|
|
|
AMLODIPINE BENZOATE 1 MG/ML PO SUSP
|
Facility
|
IP
|
$4.43
|
|
|
Service Code
|
NDC 9999123403
|
| Hospital Charge Code |
9999123403
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.21 |
| Max. Negotiated Rate |
$2.21 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.21
|
|
|
AMLODIPINE BENZOATE 1 MG/ML PO SUSP
|
Facility
|
OP
|
$4.43
|
|
|
Service Code
|
NDC 9999123403
|
| Hospital Charge Code |
9999123403
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.55 |
| Max. Negotiated Rate |
$3.54 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2.44
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.21
|
| Rate for Payer: Aetna Government |
$2.21
|
| Rate for Payer: Brighton Health Commercial |
$3.32
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$3.54
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$3.01
|
| Rate for Payer: EmblemHealth Commercial |
$2.21
|
| Rate for Payer: Group Health Inc Commercial |
$2.21
|
| Rate for Payer: Group Health Inc Medicare |
$1.55
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.21
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2.21
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2.88
|
|
|
AMLODIPINE BESYLATE 10 MG PO TABS
|
Facility
|
OP
|
$2.26
|
|
|
Service Code
|
NDC 0904637161
|
| Hospital Charge Code |
0904637161
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.79 |
| Max. Negotiated Rate |
$1.80 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.24
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.13
|
| Rate for Payer: Aetna Government |
$1.13
|
| Rate for Payer: Brighton Health Commercial |
$1.69
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.80
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.53
|
| Rate for Payer: EmblemHealth Commercial |
$1.13
|
| Rate for Payer: Group Health Inc Commercial |
$1.13
|
| Rate for Payer: Group Health Inc Medicare |
$0.79
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.13
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.13
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.47
|
|
