|
ACETAZOLAMIDE 250 MG PO TABS [113]
|
Facility
|
OP
|
$4.19
|
|
|
Service Code
|
NDC 50268005411
|
| Hospital Charge Code |
50268005411
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.47 |
| Max. Negotiated Rate |
$3.35 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2.30
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.09
|
| Rate for Payer: Aetna Government |
$2.09
|
| Rate for Payer: Brighton Health Commercial |
$3.14
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$3.35
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2.85
|
| Rate for Payer: Group Health Inc Commercial |
$2.09
|
| Rate for Payer: Group Health Inc Medicare |
$1.47
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.09
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2.09
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2.72
|
|
|
ACETAZOLAMIDE 250 MG TAB
|
Facility
|
OP
|
$1.05
|
|
| Hospital Charge Code |
41644020
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$0.84 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.58
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.53
|
| Rate for Payer: Aetna Government |
$0.53
|
| Rate for Payer: Brighton Health Commercial |
$0.79
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.84
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.71
|
| Rate for Payer: Group Health Inc Commercial |
$0.53
|
| Rate for Payer: Group Health Inc Medicare |
$0.37
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.53
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.53
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.68
|
|
|
ACETAZOLAMIDE 250 MG TAB
|
Facility
|
OP
|
$1.05
|
|
| Hospital Charge Code |
41654020
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$0.84 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.58
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.53
|
| Rate for Payer: Aetna Government |
$0.53
|
| Rate for Payer: Brighton Health Commercial |
$0.79
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.84
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.71
|
| Rate for Payer: Group Health Inc Commercial |
$0.53
|
| Rate for Payer: Group Health Inc Medicare |
$0.37
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.53
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.53
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.68
|
|
|
ACETAZOLAMIDE 500 MG ERC
|
Facility
|
OP
|
$7.00
|
|
| Hospital Charge Code |
41653046
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.45 |
| Max. Negotiated Rate |
$5.60 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$3.85
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3.50
|
| Rate for Payer: Aetna Government |
$3.50
|
| Rate for Payer: Brighton Health Commercial |
$5.25
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$5.60
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$4.76
|
| Rate for Payer: Group Health Inc Commercial |
$3.50
|
| Rate for Payer: Group Health Inc Medicare |
$2.45
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$3.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$3.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$4.55
|
|
|
ACETAZOLAMIDE 500 MG ERC
|
Facility
|
OP
|
$7.00
|
|
| Hospital Charge Code |
41643046
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.45 |
| Max. Negotiated Rate |
$5.60 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$3.85
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3.50
|
| Rate for Payer: Aetna Government |
$3.50
|
| Rate for Payer: Brighton Health Commercial |
$5.25
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$5.60
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$4.76
|
| Rate for Payer: Group Health Inc Commercial |
$3.50
|
| Rate for Payer: Group Health Inc Medicare |
$2.45
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$3.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$3.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$4.55
|
|
|
ACETAZOLAMIDE 500 MG INJ
|
Facility
|
IP
|
$49.48
|
|
|
Service Code
|
HCPCS J1120
|
| Hospital Charge Code |
41640484
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.74 |
| Max. Negotiated Rate |
$24.74 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$24.74
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$24.74
|
|
|
ACETAZOLAMIDE 500 MG INJ
|
Facility
|
OP
|
$49.48
|
|
|
Service Code
|
HCPCS J1120
|
| Hospital Charge Code |
41650484
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.32 |
| Max. Negotiated Rate |
$32.16 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$27.21
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$20.13
|
| Rate for Payer: Aetna Government |
$20.13
|
| Rate for Payer: Brighton Health Commercial |
$29.69
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$24.74
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$28.45
|
| Rate for Payer: Group Health Inc Commercial |
$24.74
|
| Rate for Payer: Group Health Inc Medicare |
$17.32
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$24.74
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$24.74
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$27.81
|
| Rate for Payer: SOMOS Essential |
$27.81
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$32.16
|
|
|
ACETAZOLAMIDE 500 MG INJ
|
Facility
|
OP
|
$49.48
|
|
|
Service Code
|
HCPCS J1120
|
| Hospital Charge Code |
41640484
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.32 |
| Max. Negotiated Rate |
$32.16 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$27.21
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$20.13
|
| Rate for Payer: Aetna Government |
$20.13
|
| Rate for Payer: Brighton Health Commercial |
$29.69
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$24.74
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$28.45
|
| Rate for Payer: Group Health Inc Commercial |
$24.74
|
| Rate for Payer: Group Health Inc Medicare |
$17.32
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$24.74
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$24.74
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$27.81
|
| Rate for Payer: SOMOS Essential |
$27.81
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$32.16
|
|
|
ACETAZOLAMIDE 500 MG INJ
|
Facility
|
IP
|
$49.48
|
|
|
Service Code
|
HCPCS J1120
|
| Hospital Charge Code |
41650484
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.74 |
| Max. Negotiated Rate |
$24.74 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$24.74
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$24.74
|
|
|
ACETAZOLAMIDE 50 MG/ML SUSPENSION PEDIATRIC (SBH) [408119]
|
Facility
|
OP
|
$4.76
|
|
|
Service Code
|
HCPCS J1120
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.67 |
| Max. Negotiated Rate |
$27.81 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2.62
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$20.13
|
| Rate for Payer: Aetna Government |
$20.13
|
| Rate for Payer: Brighton Health Commercial |
$3.57
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$3.81
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$3.24
|
| Rate for Payer: Group Health Inc Commercial |
$2.38
|
| Rate for Payer: Group Health Inc Medicare |
$1.67
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.38
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2.38
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$26.23
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$27.81
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$27.81
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$27.81
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3.10
|
|
|
ACETAZOLAMIDE 5 MG/ML INJ PEDIATRIC
|
Facility
|
OP
|
$1.88
|
|
| Hospital Charge Code |
41643060
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.66 |
| Max. Negotiated Rate |
$1.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.03
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.94
|
| Rate for Payer: Aetna Government |
$0.94
|
| Rate for Payer: Brighton Health Commercial |
$1.41
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.50
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.28
|
| Rate for Payer: Group Health Inc Commercial |
$0.94
|
| Rate for Payer: Group Health Inc Medicare |
$0.66
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.94
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.94
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.22
|
|
|
ACETAZOLAMIDE 5 MG/ML INJ PEDIATRIC
|
Facility
|
OP
|
$1.88
|
|
| Hospital Charge Code |
41653060
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.66 |
| Max. Negotiated Rate |
$1.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.03
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.94
|
| Rate for Payer: Aetna Government |
$0.94
|
| Rate for Payer: Brighton Health Commercial |
$1.41
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.50
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.28
|
| Rate for Payer: Group Health Inc Commercial |
$0.94
|
| Rate for Payer: Group Health Inc Medicare |
$0.66
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.94
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.94
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.22
|
|
|
ACETAZOLAMIDE 5MG/ML INJ PEDIATRIC (SBH) [409114]
|
Facility
|
OP
|
$4.76
|
|
|
Service Code
|
HCPCS J1120
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.67 |
| Max. Negotiated Rate |
$27.81 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2.62
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$20.13
|
| Rate for Payer: Aetna Government |
$20.13
|
| Rate for Payer: Brighton Health Commercial |
$3.57
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$3.81
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$3.24
|
| Rate for Payer: Group Health Inc Commercial |
$2.38
|
| Rate for Payer: Group Health Inc Medicare |
$1.67
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.38
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2.38
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$26.23
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$27.81
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$27.81
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$27.81
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3.10
|
|
|
ACETAZOLAMIDE ER 500 MG PO CP12 [8962]
|
Facility
|
OP
|
$4.29
|
|
|
Service Code
|
NDC 70710159101
|
| Hospital Charge Code |
70710159101
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$3.44 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2.36
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.15
|
| Rate for Payer: Aetna Government |
$2.15
|
| Rate for Payer: Brighton Health Commercial |
$3.22
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$3.44
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2.92
|
| Rate for Payer: Group Health Inc Commercial |
$2.15
|
| Rate for Payer: Group Health Inc Medicare |
$1.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.15
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2.15
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2.79
|
|
|
ACETAZOLAMIDE ER 500 MG PO CP12 [8962]
|
Facility
|
OP
|
$4.29
|
|
|
Service Code
|
NDC 50742023301
|
| Hospital Charge Code |
50742023301
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$3.44 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2.36
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.15
|
| Rate for Payer: Aetna Government |
$2.15
|
| Rate for Payer: Brighton Health Commercial |
$3.22
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$3.44
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2.92
|
| Rate for Payer: Group Health Inc Commercial |
$2.15
|
| Rate for Payer: Group Health Inc Medicare |
$1.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.15
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2.15
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2.79
|
|
|
ACETAZOLAMIDE ER 500 MG PO CP12 [8962]
|
Facility
|
OP
|
$4.29
|
|
|
Service Code
|
NDC 16729033101
|
| Hospital Charge Code |
16729033101
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$3.44 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2.36
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.15
|
| Rate for Payer: Aetna Government |
$2.15
|
| Rate for Payer: Brighton Health Commercial |
$3.22
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$3.44
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2.92
|
| Rate for Payer: Group Health Inc Commercial |
$2.15
|
| Rate for Payer: Group Health Inc Medicare |
$1.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.15
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2.15
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2.79
|
|
|
ACETAZOLAMIDE SODIUM 500 MG IJ SOLR [114]
|
Facility
|
OP
|
$39.38
|
|
|
Service Code
|
HCPCS J1120
|
| Hospital Charge Code |
39822019001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.78 |
| Max. Negotiated Rate |
$31.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$21.66
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$20.13
|
| Rate for Payer: Aetna Government |
$20.13
|
| Rate for Payer: Brighton Health Commercial |
$29.54
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$31.50
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$26.78
|
| Rate for Payer: Group Health Inc Commercial |
$19.69
|
| Rate for Payer: Group Health Inc Medicare |
$13.78
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$19.69
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$19.69
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$26.23
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$27.81
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$27.81
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$27.81
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$25.60
|
|
|
ACETAZOLAMIDE SODIUM 500 MG IJ SOLR [114]
|
Facility
|
OP
|
$47.64
|
|
|
Service Code
|
HCPCS J1120
|
| Hospital Charge Code |
23155031331
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.67 |
| Max. Negotiated Rate |
$38.11 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$26.20
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$20.13
|
| Rate for Payer: Aetna Government |
$20.13
|
| Rate for Payer: Brighton Health Commercial |
$35.73
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$38.11
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$32.40
|
| Rate for Payer: Group Health Inc Commercial |
$23.82
|
| Rate for Payer: Group Health Inc Medicare |
$16.67
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$23.82
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$23.82
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$26.23
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$27.81
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$27.81
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$27.81
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$30.97
|
|
|
ACETAZOLAMIDE SODIUM 500 MG IJ SOLR [114]
|
Facility
|
OP
|
$48.00
|
|
|
Service Code
|
HCPCS J1120
|
| Hospital Charge Code |
67457085350
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.80 |
| Max. Negotiated Rate |
$38.40 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$26.40
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$20.13
|
| Rate for Payer: Aetna Government |
$20.13
|
| Rate for Payer: Brighton Health Commercial |
$36.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$38.40
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$32.64
|
| Rate for Payer: Group Health Inc Commercial |
$24.00
|
| Rate for Payer: Group Health Inc Medicare |
$16.80
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$24.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$24.00
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$26.23
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$27.81
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$27.81
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$27.81
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$31.20
|
|
|
ACETIC ACID 0.25 % IR SOLN [8963]
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
NDC 00338065604
|
| Hospital Charge Code |
00338065604
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.00
|
| Rate for Payer: Aetna Government |
$0.00
|
| Rate for Payer: Brighton Health Commercial |
$0.01
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.01
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.01
|
| Rate for Payer: Group Health Inc Commercial |
$0.00
|
| Rate for Payer: Group Health Inc Medicare |
$0.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.01
|
|
|
ACETIC ACID 2 % OT SOLN [17801]
|
Facility
|
OP
|
$3.20
|
|
|
Service Code
|
NDC 52817081615
|
| Hospital Charge Code |
52817081615
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.12 |
| Max. Negotiated Rate |
$2.56 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.76
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.60
|
| Rate for Payer: Aetna Government |
$1.60
|
| Rate for Payer: Brighton Health Commercial |
$2.40
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2.56
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2.18
|
| Rate for Payer: Group Health Inc Commercial |
$1.60
|
| Rate for Payer: Group Health Inc Medicare |
$1.12
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.60
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.60
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2.08
|
|
|
ACETIC ACID 2 % OT SOLN [17801]
|
Facility
|
OP
|
$2.67
|
|
|
Service Code
|
NDC 60432074116
|
| Hospital Charge Code |
60432074116
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.93 |
| Max. Negotiated Rate |
$2.13 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.47
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.33
|
| Rate for Payer: Aetna Government |
$1.33
|
| Rate for Payer: Brighton Health Commercial |
$2.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2.13
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.81
|
| Rate for Payer: Group Health Inc Commercial |
$1.33
|
| Rate for Payer: Group Health Inc Medicare |
$0.93
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.33
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.33
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.73
|
|
|
ACETIC ACID 3% TOPICAL SOLN
|
Facility
|
OP
|
$1.00
|
|
| Hospital Charge Code |
41644618
|
|
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
|
|
|
ACETIC ACID 3% TOPICAL SOLN
|
Facility
|
OP
|
$1.00
|
|
| Hospital Charge Code |
41654618
|
|
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
|
|
|
ACETIC ACID IRRIGATION 0.25% SOLN
|
Facility
|
OP
|
$4.00
|
|
| Hospital Charge Code |
41651274
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.40 |
| Max. Negotiated Rate |
$3.20 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2.20
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.00
|
| Rate for Payer: Aetna Government |
$2.00
|
| Rate for Payer: Brighton Health Commercial |
$3.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$3.20
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2.72
|
| Rate for Payer: Group Health Inc Commercial |
$2.00
|
| Rate for Payer: Group Health Inc Medicare |
$1.40
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2.60
|
|
