|
CHLORAMBUCIL 2 MG TAB
|
Facility
|
OP
|
$7.00
|
|
|
Service Code
|
HCPCS J8999
|
| Hospital Charge Code |
41644054
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.45 |
| Max. Negotiated Rate |
$4.55 |
| 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 |
$4.20
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$3.50
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$4.02
|
| 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
|
|
|
CHLORAMBUCIL 2 MG TAB
|
Facility
|
IP
|
$7.00
|
|
|
Service Code
|
HCPCS J8999
|
| Hospital Charge Code |
41644054
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.50 |
| Max. Negotiated Rate |
$3.50 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$3.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$3.50
|
|
|
CHLORAMPHENICOL 1000 MG INJ
|
Facility
|
OP
|
$47.38
|
|
|
Service Code
|
HCPCS J0720
|
| Hospital Charge Code |
41653551
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.58 |
| Max. Negotiated Rate |
$36.32 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$26.06
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$36.32
|
| Rate for Payer: Aetna Government |
$36.32
|
| Rate for Payer: Brighton Health Commercial |
$28.43
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$23.69
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$27.24
|
| Rate for Payer: Group Health Inc Commercial |
$23.69
|
| Rate for Payer: Group Health Inc Medicare |
$16.58
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$23.69
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$23.69
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$30.80
|
|
|
CHLORAMPHENICOL 1000 MG INJ
|
Facility
|
IP
|
$47.38
|
|
|
Service Code
|
HCPCS J0720
|
| Hospital Charge Code |
41653551
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.69 |
| Max. Negotiated Rate |
$23.69 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$23.69
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$23.69
|
|
|
CHLORAMPHENICOL 1000 MG INJ
|
Facility
|
IP
|
$47.38
|
|
|
Service Code
|
HCPCS J0720
|
| Hospital Charge Code |
41643551
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.69 |
| Max. Negotiated Rate |
$23.69 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$23.69
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$23.69
|
|
|
CHLORAMPHENICOL 1000 MG INJ
|
Facility
|
OP
|
$47.38
|
|
|
Service Code
|
HCPCS J0720
|
| Hospital Charge Code |
41643551
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.58 |
| Max. Negotiated Rate |
$36.32 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$26.06
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$36.32
|
| Rate for Payer: Aetna Government |
$36.32
|
| Rate for Payer: Brighton Health Commercial |
$28.43
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$23.69
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$27.24
|
| Rate for Payer: Group Health Inc Commercial |
$23.69
|
| Rate for Payer: Group Health Inc Medicare |
$16.58
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$23.69
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$23.69
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$30.80
|
|
|
CHLORA PREP
|
Facility
|
OP
|
$0.12
|
|
| Hospital Charge Code |
40209487
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.10 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.07
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.06
|
| Rate for Payer: Aetna Government |
$0.06
|
| Rate for Payer: Brighton Health Commercial |
$0.09
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.10
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.08
|
| Rate for Payer: Group Health Inc Commercial |
$0.06
|
| Rate for Payer: Group Health Inc Medicare |
$0.04
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.06
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.06
|
|
|
CHLORDIAZEPOXIDE 10 MG CAP
|
Facility
|
OP
|
$0.25
|
|
| Hospital Charge Code |
41644099
|
|
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
|
|
|
CHLORDIAZEPOXIDE 10 MG CAP
|
Facility
|
OP
|
$0.25
|
|
| Hospital Charge Code |
41654099
|
|
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
|
|
|
CHLORDIAZEPOXIDE 25 MG CAP
|
Facility
|
OP
|
$0.27
|
|
| Hospital Charge Code |
41653349
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.09 |
| 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 |
$0.20
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.22
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.18
|
| Rate for Payer: Group Health Inc Commercial |
$0.14
|
| Rate for Payer: Group Health Inc Medicare |
$0.09
|
| 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
|
|
|
CHLORDIAZEPOXIDE 25 MG CAP
|
Facility
|
OP
|
$0.27
|
|
| Hospital Charge Code |
41643349
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.09 |
| 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 |
$0.20
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.22
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.18
|
| Rate for Payer: Group Health Inc Commercial |
$0.14
|
| Rate for Payer: Group Health Inc Medicare |
$0.09
|
| 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
|
|
|
CHLORDIAZEPOXIDE 5 MG CAP
|
Facility
|
OP
|
$1.00
|
|
| Hospital Charge Code |
41642598
|
|
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
|
|
|
CHLORDIAZEPOXIDE 5 MG CAP
|
Facility
|
OP
|
$1.00
|
|
| Hospital Charge Code |
41652598
|
|
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
|
|
|
CHLORDIAZEPOXIDE HCL 10 MG PO CAPS [1622]
|
Facility
|
OP
|
$0.62
|
|
|
Service Code
|
NDC 51079037520
|
| Hospital Charge Code |
51079037520
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$0.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.34
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.31
|
| Rate for Payer: Aetna Government |
$0.31
|
| Rate for Payer: Brighton Health Commercial |
$0.47
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.50
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.42
|
| Rate for Payer: Group Health Inc Commercial |
$0.31
|
| Rate for Payer: Group Health Inc Medicare |
$0.22
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.31
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.31
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.40
|
|
|
CHLORDIAZEPOXIDE HCL 10 MG PO CAPS [1622]
|
Facility
|
OP
|
$0.62
|
|
|
Service Code
|
NDC 51079037501
|
| Hospital Charge Code |
51079037501
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$0.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.34
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.31
|
| Rate for Payer: Aetna Government |
$0.31
|
| Rate for Payer: Brighton Health Commercial |
$0.47
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.50
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.42
|
| Rate for Payer: Group Health Inc Commercial |
$0.31
|
| Rate for Payer: Group Health Inc Medicare |
$0.22
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.31
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.31
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.40
|
|
|
CHLORDIAZEPOXIDE HCL 10 MG PO CAPS [1622]
|
Facility
|
OP
|
$0.40
|
|
|
Service Code
|
NDC 00555003302
|
| Hospital Charge Code |
00555003302
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.22
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.20
|
| Rate for Payer: Aetna Government |
$0.20
|
| Rate for Payer: Brighton Health Commercial |
$0.30
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.32
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.27
|
| Rate for Payer: Group Health Inc Commercial |
$0.20
|
| Rate for Payer: Group Health Inc Medicare |
$0.14
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.20
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.20
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.26
|
|
|
CHLORDIAZEPOXIDE HCL 25 MG PO CAPS [1623]
|
Facility
|
OP
|
$0.67
|
|
|
Service Code
|
NDC 51079014101
|
| Hospital Charge Code |
51079014101
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.54 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.37
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.34
|
| Rate for Payer: Aetna Government |
$0.34
|
| Rate for Payer: Brighton Health Commercial |
$0.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.54
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.46
|
| Rate for Payer: Group Health Inc Commercial |
$0.34
|
| Rate for Payer: Group Health Inc Medicare |
$0.23
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.34
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.34
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.44
|
|
|
CHLORDIAZEPOXIDE HCL 25 MG PO CAPS [1623]
|
Facility
|
OP
|
$0.67
|
|
|
Service Code
|
NDC 51079014120
|
| Hospital Charge Code |
51079014120
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.54 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.37
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.33
|
| Rate for Payer: Aetna Government |
$0.33
|
| Rate for Payer: Brighton Health Commercial |
$0.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.54
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.45
|
| Rate for Payer: Group Health Inc Commercial |
$0.33
|
| Rate for Payer: Group Health Inc Medicare |
$0.23
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.33
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.33
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.43
|
|
|
CHLORDIAZEPOXIDE HCL 25 MG PO CAPS [1623]
|
Facility
|
OP
|
$22.33
|
|
|
Service Code
|
NDC 42806056301
|
| Hospital Charge Code |
42806056301
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.81 |
| Max. Negotiated Rate |
$17.86 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$12.28
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$11.16
|
| Rate for Payer: Aetna Government |
$11.16
|
| Rate for Payer: Brighton Health Commercial |
$16.74
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$17.86
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$15.18
|
| Rate for Payer: Group Health Inc Commercial |
$11.16
|
| Rate for Payer: Group Health Inc Medicare |
$7.81
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$11.16
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$11.16
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$14.51
|
|
|
CHLORDIAZEPOXIDE HCL 25 MG PO CAPS [1623]
|
Facility
|
OP
|
$0.43
|
|
|
Service Code
|
NDC 00555015902
|
| Hospital Charge Code |
00555015902
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.34 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.24
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.21
|
| Rate for Payer: Aetna Government |
$0.21
|
| Rate for Payer: Brighton Health Commercial |
$0.32
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.34
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.29
|
| Rate for Payer: Group Health Inc Commercial |
$0.21
|
| Rate for Payer: Group Health Inc Medicare |
$0.15
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.21
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.21
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.28
|
|
|
CHLORDIAZEPOXIDE HCL 25 MG PO CAPS [1623]
|
Facility
|
OP
|
$0.31
|
|
|
Service Code
|
NDC 00555015904
|
| Hospital Charge Code |
00555015904
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.24 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.17
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.15
|
| Rate for Payer: Aetna Government |
$0.15
|
| Rate for Payer: Brighton Health Commercial |
$0.23
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.24
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.21
|
| Rate for Payer: Group Health Inc Commercial |
$0.15
|
| Rate for Payer: Group Health Inc Medicare |
$0.11
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.15
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.15
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.20
|
|
|
CHLORDIAZEPOXIDE HCL 5 MG PO CAPS [1624]
|
Facility
|
OP
|
$0.81
|
|
|
Service Code
|
NDC 51079037420
|
| Hospital Charge Code |
51079037420
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$0.65 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.45
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.41
|
| Rate for Payer: Aetna Government |
$0.41
|
| Rate for Payer: Brighton Health Commercial |
$0.61
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.65
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.55
|
| Rate for Payer: Group Health Inc Commercial |
$0.41
|
| Rate for Payer: Group Health Inc Medicare |
$0.28
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.41
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.41
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.53
|
|
|
CHLORDIAZEPOXIDE HCL 5 MG PO CAPS [1624]
|
Facility
|
OP
|
$0.29
|
|
|
Service Code
|
NDC 00555015804
|
| Hospital Charge Code |
00555015804
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.16
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.14
|
| Rate for Payer: Aetna Government |
$0.14
|
| Rate for Payer: Brighton Health Commercial |
$0.22
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.23
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.20
|
| 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 |
$0.19
|
|
|
CHLORDIAZEPOXIDE HCL 5 MG PO CAPS [1624]
|
Facility
|
OP
|
$0.35
|
|
|
Service Code
|
NDC 00555015802
|
| Hospital Charge Code |
00555015802
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.28 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.19
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.18
|
| Rate for Payer: Aetna Government |
$0.18
|
| Rate for Payer: Brighton Health Commercial |
$0.26
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.28
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.24
|
| Rate for Payer: Group Health Inc Commercial |
$0.18
|
| Rate for Payer: Group Health Inc Medicare |
$0.12
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.18
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.18
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.23
|
|
|
CHLORHEXIDINE 0.12% 15ML
|
Facility
|
OP
|
$0.10
|
|
| Hospital Charge Code |
41658451
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.06
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.05
|
| Rate for Payer: Aetna Government |
$0.05
|
| Rate for Payer: Brighton Health Commercial |
$0.08
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.08
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.07
|
| Rate for Payer: Group Health Inc Commercial |
$0.05
|
| Rate for Payer: Group Health Inc Medicare |
$0.04
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.05
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.05
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.07
|
|
