|
CABOTEGRAVIR + RILPIVIRINE 4ML
|
Facility
|
OP
|
$23.76
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
41640249
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.32 |
| Max. Negotiated Rate |
$15.44 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$13.07
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$11.88
|
| Rate for Payer: Aetna Government |
$11.88
|
| Rate for Payer: Brighton Health Commercial |
$14.26
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$11.88
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$13.66
|
| Rate for Payer: Group Health Inc Commercial |
$11.88
|
| Rate for Payer: Group Health Inc Medicare |
$8.32
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$11.88
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$11.88
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$15.44
|
|
|
CABOTEGRAVIR + RILPIVIRINE 6ML
|
Facility
|
OP
|
$23.76
|
|
|
Service Code
|
HCPCS J0741
|
| Hospital Charge Code |
41640260
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.88 |
| Max. Negotiated Rate |
$23.97 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$13.07
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$22.60
|
| Rate for Payer: Aetna Government |
$22.60
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$15.82
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$15.82
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$15.82
|
| Rate for Payer: Brighton Health Commercial |
$14.26
|
| Rate for Payer: Cash Price |
$22.60
|
| Rate for Payer: Cash Price |
$22.60
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$22.60
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$11.88
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$13.66
|
| Rate for Payer: Elderplan Medicare Advantage |
$22.60
|
| Rate for Payer: EmblemHealth Commercial |
$22.60
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$22.60
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$22.60
|
| Rate for Payer: Fidelis Essential Plan QHP |
$23.73
|
| Rate for Payer: Fidelis Medicare Advantage |
$22.60
|
| Rate for Payer: Fidelis Qualified Health Plan |
$23.73
|
| Rate for Payer: Group Health Inc Commercial |
$22.60
|
| Rate for Payer: Group Health Inc Medicare |
$22.60
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$11.88
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$11.88
|
| Rate for Payer: Healthfirst Medicare Advantage |
$19.21
|
| Rate for Payer: Healthfirst QHP |
$22.60
|
| Rate for Payer: Humana Medicare |
$23.05
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$22.60
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$23.97
|
| Rate for Payer: SOMOS Essential |
$23.97
|
| Rate for Payer: United Healthcare Commercial |
$21.56
|
| Rate for Payer: United Healthcare Medicare Advantage |
$22.60
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$15.44
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$18.08
|
| Rate for Payer: Wellcare Medicare |
$21.47
|
|
|
CABOTEGRAVIR + RILPIVIRINE 6ML
|
Facility
|
IP
|
$23.76
|
|
|
Service Code
|
HCPCS J0741
|
| Hospital Charge Code |
41640260
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.88 |
| Max. Negotiated Rate |
$11.88 |
| Rate for Payer: Cash Price |
$22.60
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$11.88
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$11.88
|
|
|
CABOTEGRAVIR + RILPIVIRINE 6ML
|
Facility
|
IP
|
$23.76
|
|
|
Service Code
|
HCPCS J0741
|
| Hospital Charge Code |
41650260
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.88 |
| Max. Negotiated Rate |
$11.88 |
| Rate for Payer: Cash Price |
$22.60
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$11.88
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$11.88
|
|
|
CABOTEGRAVIR + RILPIVIRINE 6ML
|
Facility
|
OP
|
$23.76
|
|
|
Service Code
|
HCPCS J0741
|
| Hospital Charge Code |
41650260
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.88 |
| Max. Negotiated Rate |
$23.97 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$13.07
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$22.60
|
| Rate for Payer: Aetna Government |
$22.60
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$15.82
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$15.82
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$15.82
|
| Rate for Payer: Brighton Health Commercial |
$14.26
|
| Rate for Payer: Cash Price |
$22.60
|
| Rate for Payer: Cash Price |
$22.60
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$22.60
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$11.88
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$13.66
|
| Rate for Payer: Elderplan Medicare Advantage |
$22.60
|
| Rate for Payer: EmblemHealth Commercial |
$22.60
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$22.60
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$22.60
|
| Rate for Payer: Fidelis Essential Plan QHP |
$23.73
|
| Rate for Payer: Fidelis Medicare Advantage |
$22.60
|
| Rate for Payer: Fidelis Qualified Health Plan |
$23.73
|
| Rate for Payer: Group Health Inc Commercial |
$22.60
|
| Rate for Payer: Group Health Inc Medicare |
$22.60
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$11.88
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$11.88
|
| Rate for Payer: Healthfirst Medicare Advantage |
$19.21
|
| Rate for Payer: Healthfirst QHP |
$22.60
|
| Rate for Payer: Humana Medicare |
$23.05
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$22.60
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$23.97
|
| Rate for Payer: SOMOS Essential |
$23.97
|
| Rate for Payer: United Healthcare Commercial |
$21.56
|
| Rate for Payer: United Healthcare Medicare Advantage |
$22.60
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$15.44
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$18.08
|
| Rate for Payer: Wellcare Medicare |
$21.47
|
|
|
CABOTEGRAVIR & RILPIVIRINE ER 400 & 600 MG/2ML IM SUER [177303]
|
Facility
|
OP
|
$1,305.16
|
|
|
Service Code
|
HCPCS J0741
|
| Hospital Charge Code |
49702025315
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.82 |
| Max. Negotiated Rate |
$1,044.12 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$717.84
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$22.60
|
| Rate for Payer: Aetna Government |
$22.60
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$15.82
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$15.82
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$15.82
|
| Rate for Payer: Brighton Health Commercial |
$978.87
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$22.60
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,044.12
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$887.51
|
| Rate for Payer: Elderplan Medicare Advantage |
$22.60
|
| Rate for Payer: EmblemHealth Commercial |
$22.60
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$19.21
|
| Rate for Payer: Fidelis Essential Plan QHP |
$20.11
|
| Rate for Payer: Fidelis Medicare Advantage |
$22.60
|
| Rate for Payer: Fidelis Qualified Health Plan |
$20.11
|
| Rate for Payer: Group Health Inc Commercial |
$22.60
|
| Rate for Payer: Group Health Inc Medicare |
$22.60
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$652.58
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$22.60
|
| Rate for Payer: Healthfirst Medicare Advantage |
$19.21
|
| Rate for Payer: Healthfirst QHP |
$22.60
|
| Rate for Payer: Humana Medicare |
$23.05
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$22.62
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$23.97
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$23.97
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$23.97
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$22.60
|
| Rate for Payer: United Healthcare Medicare Advantage |
$22.60
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$848.35
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$18.08
|
| Rate for Payer: Wellcare Medicare |
$21.47
|
|
|
CABOTEGRAVIR & RILPIVIRINE ER 600 & 900 MG/3ML IM SUER [177304]
|
Facility
|
OP
|
$1,305.16
|
|
|
Service Code
|
HCPCS J0741
|
| Hospital Charge Code |
49702024015
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.82 |
| Max. Negotiated Rate |
$1,044.13 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$717.84
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$22.60
|
| Rate for Payer: Aetna Government |
$22.60
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$15.82
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$15.82
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$15.82
|
| Rate for Payer: Brighton Health Commercial |
$978.87
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$22.60
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,044.13
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$887.51
|
| Rate for Payer: Elderplan Medicare Advantage |
$22.60
|
| Rate for Payer: EmblemHealth Commercial |
$22.60
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$19.21
|
| Rate for Payer: Fidelis Essential Plan QHP |
$20.11
|
| Rate for Payer: Fidelis Medicare Advantage |
$22.60
|
| Rate for Payer: Fidelis Qualified Health Plan |
$20.11
|
| Rate for Payer: Group Health Inc Commercial |
$22.60
|
| Rate for Payer: Group Health Inc Medicare |
$22.60
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$652.58
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$22.60
|
| Rate for Payer: Healthfirst Medicare Advantage |
$19.21
|
| Rate for Payer: Healthfirst QHP |
$22.60
|
| Rate for Payer: Humana Medicare |
$23.05
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$22.62
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$23.97
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$23.97
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$23.97
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$22.60
|
| Rate for Payer: United Healthcare Medicare Advantage |
$22.60
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$848.35
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$18.08
|
| Rate for Payer: Wellcare Medicare |
$21.47
|
|
|
CADMIUM, URINE
|
Facility
|
OP
|
$59.10
|
|
|
Service Code
|
HCPCS 82300
|
| Hospital Charge Code |
40608277
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$16.55 |
| Max. Negotiated Rate |
$44.32 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$32.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$23.64
|
| Rate for Payer: Aetna Government |
$23.64
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$16.55
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$16.55
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$16.55
|
| Rate for Payer: Brighton Health Commercial |
$44.32
|
| Rate for Payer: Cash Price |
$23.64
|
| Rate for Payer: Cash Price |
$23.64
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$23.64
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$36.78
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$31.12
|
| Rate for Payer: Elderplan Medicare Advantage |
$23.64
|
| Rate for Payer: EmblemHealth Commercial |
$23.64
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$20.09
|
| Rate for Payer: Fidelis Essential Plan QHP |
$21.04
|
| Rate for Payer: Fidelis Medicare Advantage |
$23.64
|
| Rate for Payer: Fidelis Qualified Health Plan |
$21.04
|
| Rate for Payer: Group Health Inc Commercial |
$23.64
|
| Rate for Payer: Group Health Inc Medicare |
$23.64
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$29.55
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$23.64
|
| Rate for Payer: Healthfirst Medicare Advantage |
$23.64
|
| Rate for Payer: Healthfirst QHP |
$23.64
|
| Rate for Payer: Humana Medicare |
$24.11
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$23.64
|
| Rate for Payer: United Healthcare Commercial |
$29.31
|
| Rate for Payer: United Healthcare Medicare Advantage |
$23.64
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$23.64
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$18.91
|
| Rate for Payer: Wellcare Medicare |
$21.28
|
|
|
CADMIUM, URINE
|
Facility
|
IP
|
$59.10
|
|
|
Service Code
|
HCPCS 82300
|
| Hospital Charge Code |
40608277
|
|
Hospital Revenue Code
|
301
|
| Rate for Payer: Cash Price |
$23.64
|
|
|
CAFFEINE CITRATE 20 MG/ML INJ
|
Facility
|
OP
|
$5.88
|
|
|
Service Code
|
HCPCS J0706
|
| Hospital Charge Code |
41643155
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.69 |
| Max. Negotiated Rate |
$3.82 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$3.23
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.69
|
| Rate for Payer: Aetna Government |
$0.69
|
| Rate for Payer: Brighton Health Commercial |
$3.53
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2.94
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$3.38
|
| Rate for Payer: Group Health Inc Commercial |
$2.94
|
| Rate for Payer: Group Health Inc Medicare |
$2.06
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.94
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2.94
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3.82
|
|
|
CAFFEINE CITRATE 20 MG/ML INJ
|
Facility
|
IP
|
$5.88
|
|
|
Service Code
|
HCPCS J0706
|
| Hospital Charge Code |
41643155
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.94 |
| Max. Negotiated Rate |
$2.94 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.94
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2.94
|
|
|
CAFFEINE CITRATE 20 MG/ML INJ
|
Facility
|
IP
|
$5.88
|
|
|
Service Code
|
HCPCS J0706
|
| Hospital Charge Code |
41653155
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.94 |
| Max. Negotiated Rate |
$2.94 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.94
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2.94
|
|
|
CAFFEINE CITRATE 20 MG/ML INJ
|
Facility
|
OP
|
$5.88
|
|
|
Service Code
|
HCPCS J0706
|
| Hospital Charge Code |
41653155
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.69 |
| Max. Negotiated Rate |
$3.82 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$3.23
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.69
|
| Rate for Payer: Aetna Government |
$0.69
|
| Rate for Payer: Brighton Health Commercial |
$3.53
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2.94
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$3.38
|
| Rate for Payer: Group Health Inc Commercial |
$2.94
|
| Rate for Payer: Group Health Inc Medicare |
$2.06
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.94
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2.94
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3.82
|
|
|
CAFFEINE CITRATE 20 MG/ML LIQUID NEONATA
|
Facility
|
OP
|
$34.00
|
|
| Hospital Charge Code |
41653157
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.90 |
| Max. Negotiated Rate |
$27.20 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$18.70
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$17.00
|
| Rate for Payer: Aetna Government |
$17.00
|
| Rate for Payer: Brighton Health Commercial |
$25.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$27.20
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$23.12
|
| Rate for Payer: Group Health Inc Commercial |
$17.00
|
| Rate for Payer: Group Health Inc Medicare |
$11.90
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$17.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$17.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$22.10
|
|
|
CAFFEINE CITRATE 20 MG/ML LIQUID NEONATA
|
Facility
|
OP
|
$34.00
|
|
| Hospital Charge Code |
41643157
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.90 |
| Max. Negotiated Rate |
$27.20 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$18.70
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$17.00
|
| Rate for Payer: Aetna Government |
$17.00
|
| Rate for Payer: Brighton Health Commercial |
$25.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$27.20
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$23.12
|
| Rate for Payer: Group Health Inc Commercial |
$17.00
|
| Rate for Payer: Group Health Inc Medicare |
$11.90
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$17.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$17.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$22.10
|
|
|
CAFFEINE CITRATE 20 MG/ML PO SOLN [77411]
|
Facility
|
OP
|
$16.15
|
|
|
Service Code
|
NDC 63323040603
|
| Hospital Charge Code |
63323040603
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.65 |
| Max. Negotiated Rate |
$12.92 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$8.88
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$8.07
|
| Rate for Payer: Aetna Government |
$8.07
|
| Rate for Payer: Brighton Health Commercial |
$12.11
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$12.92
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$10.98
|
| Rate for Payer: Group Health Inc Commercial |
$8.07
|
| Rate for Payer: Group Health Inc Medicare |
$5.65
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$8.07
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$8.07
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$10.50
|
|
|
CAFFEINE CITRATE 20 MG/ML PO SOLN [77411]
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
NDC 25021060203
|
| Hospital Charge Code |
25021060203
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.80 |
| Max. Negotiated Rate |
$6.40 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$4.40
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$4.00
|
| Rate for Payer: Aetna Government |
$4.00
|
| Rate for Payer: Brighton Health Commercial |
$6.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$6.40
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$5.44
|
| Rate for Payer: Group Health Inc Commercial |
$4.00
|
| Rate for Payer: Group Health Inc Medicare |
$2.80
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$5.20
|
|
|
CAFFEINE CITRATE 20 MG/ML PO SOLN [77411]
|
Facility
|
OP
|
$7.96
|
|
|
Service Code
|
NDC 72485011010
|
| Hospital Charge Code |
72485011010
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.79 |
| Max. Negotiated Rate |
$6.37 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$4.38
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3.98
|
| Rate for Payer: Aetna Government |
$3.98
|
| Rate for Payer: Brighton Health Commercial |
$5.97
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$6.37
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$5.41
|
| Rate for Payer: Group Health Inc Commercial |
$3.98
|
| Rate for Payer: Group Health Inc Medicare |
$2.79
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$3.98
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$3.98
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$5.17
|
|
|
CAFFEINE CITRATE 60 MG/3ML IV SOLN [109034]
|
Facility
|
OP
|
$3.26
|
|
|
Service Code
|
NDC 63323040704
|
| Hospital Charge Code |
63323040704
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1.14 |
| Max. Negotiated Rate |
$3.42 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.79
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.63
|
| Rate for Payer: Aetna Government |
$1.63
|
| Rate for Payer: Brighton Health Commercial |
$1.95
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.63
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.87
|
| Rate for Payer: EmblemHealth Commercial |
$1.63
|
| Rate for Payer: Fidelis Medicare Advantage |
$3.42
|
| Rate for Payer: Group Health Inc Commercial |
$1.63
|
| Rate for Payer: Group Health Inc Medicare |
$1.14
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.63
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.63
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2.12
|
|
|
CAFFEINE CITRATE 60 MG/3ML IV SOLN [109034]
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
NDC 25021060103
|
| Hospital Charge Code |
25021060103
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2.80 |
| Max. Negotiated Rate |
$8.40 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$4.40
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$4.00
|
| Rate for Payer: Aetna Government |
$4.00
|
| Rate for Payer: Brighton Health Commercial |
$4.80
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$4.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$4.60
|
| Rate for Payer: EmblemHealth Commercial |
$4.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$8.40
|
| Rate for Payer: Group Health Inc Commercial |
$4.00
|
| Rate for Payer: Group Health Inc Medicare |
$2.80
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$5.20
|
|
|
CAFFEINE CITRATE 60 MG/3ML IV SOLN [109034]
|
Facility
|
OP
|
$12.45
|
|
|
Service Code
|
NDC 63323040703
|
| Hospital Charge Code |
63323040703
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4.36 |
| Max. Negotiated Rate |
$13.08 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$6.85
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$6.23
|
| Rate for Payer: Aetna Government |
$6.23
|
| Rate for Payer: Brighton Health Commercial |
$7.47
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$6.23
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$7.16
|
| Rate for Payer: EmblemHealth Commercial |
$6.23
|
| Rate for Payer: Fidelis Medicare Advantage |
$13.08
|
| Rate for Payer: Group Health Inc Commercial |
$6.23
|
| Rate for Payer: Group Health Inc Medicare |
$4.36
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$6.23
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$6.23
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$8.09
|
|
|
CAFFEINE CITRATE 60 MG/3ML IV SOLN [109034]
|
Facility
|
IP
|
$4.40
|
|
|
Service Code
|
NDC 72485010410
|
| Hospital Charge Code |
72485010410
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2.20 |
| Max. Negotiated Rate |
$2.20 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.20
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2.20
|
|
|
CAFFEINE CITRATE 60 MG/3ML IV SOLN [109034]
|
Facility
|
IP
|
$12.45
|
|
|
Service Code
|
NDC 63323040703
|
| Hospital Charge Code |
63323040703
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6.23 |
| Max. Negotiated Rate |
$6.23 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$6.23
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$6.23
|
|
|
CAFFEINE CITRATE 60 MG/3ML IV SOLN [109034]
|
Facility
|
IP
|
$3.26
|
|
|
Service Code
|
NDC 63323040704
|
| Hospital Charge Code |
63323040704
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1.63 |
| Max. Negotiated Rate |
$1.63 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.63
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.63
|
|
|
CAFFEINE CITRATE 60 MG/3ML IV SOLN [109034]
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
NDC 25021060103
|
| Hospital Charge Code |
25021060103
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4.00 |
| Max. Negotiated Rate |
$4.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4.00
|
|
