|
CLOSURE OF WINDPIPE LESION
|
Facility
|
OP
|
$7,933.18
|
|
|
Service Code
|
HCPCS 31820
|
| Hospital Charge Code |
40013268
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,412.00 |
| Max. Negotiated Rate |
$5,949.88 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,412.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3,723.23
|
| Rate for Payer: Aetna Government |
$3,723.23
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$2,606.26
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$2,606.26
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$2,606.26
|
| Rate for Payer: Brighton Health Commercial |
$5,949.88
|
| Rate for Payer: Cash Price |
$3,723.23
|
| Rate for Payer: Cash Price |
$3,723.23
|
| Rate for Payer: Cash Price |
$3,723.23
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$3,723.23
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2,915.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,477.75
|
| Rate for Payer: Elderplan Medicare Advantage |
$3,723.23
|
| Rate for Payer: EmblemHealth Commercial |
$1,505.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$3,164.75
|
| Rate for Payer: Fidelis Essential Plan QHP |
$3,313.67
|
| Rate for Payer: Fidelis Medicare Advantage |
$3,723.23
|
| Rate for Payer: Fidelis Qualified Health Plan |
$3,313.67
|
| Rate for Payer: Group Health Inc Commercial |
$3,723.23
|
| Rate for Payer: Group Health Inc Medicare |
$3,723.23
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$3,966.59
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$3,723.23
|
| Rate for Payer: Healthfirst Medicare Advantage |
$3,164.75
|
| Rate for Payer: Healthfirst QHP |
$3,723.23
|
| Rate for Payer: Humana Medicare |
$3,797.69
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$3,723.23
|
| Rate for Payer: United Healthcare Commercial |
$1,468.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,723.23
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3,723.23
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$2,978.58
|
| Rate for Payer: Wellcare Medicare |
$3,537.07
|
|
|
CLOSURE OF WINDPIPE LESION
|
Facility
|
IP
|
$7,933.18
|
|
|
Service Code
|
HCPCS 31820
|
| Hospital Charge Code |
40013268
|
|
Hospital Revenue Code
|
360
|
| Rate for Payer: Cash Price |
$3,723.23
|
|
|
CLOSURE TOP
|
Facility
|
OP
|
$500.00
|
|
| Hospital Charge Code |
64905986
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$175.00 |
| Max. Negotiated Rate |
$400.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$275.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$250.00
|
| Rate for Payer: Aetna Government |
$250.00
|
| Rate for Payer: Brighton Health Commercial |
$375.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$400.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$340.00
|
| Rate for Payer: Group Health Inc Commercial |
$250.00
|
| Rate for Payer: Group Health Inc Medicare |
$175.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$250.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$250.00
|
|
|
CLOSURE TOPS
|
Facility
|
OP
|
$562.50
|
|
| Hospital Charge Code |
64905977
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$196.88 |
| Max. Negotiated Rate |
$450.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$309.38
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$281.25
|
| Rate for Payer: Aetna Government |
$281.25
|
| Rate for Payer: Brighton Health Commercial |
$421.88
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$450.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$382.50
|
| Rate for Payer: Group Health Inc Commercial |
$281.25
|
| Rate for Payer: Group Health Inc Medicare |
$196.88
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$281.25
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$281.25
|
|
|
CLOSURE TOP TED SCRW W/STRTR HOL
|
Facility
|
OP
|
$375.00
|
|
| Hospital Charge Code |
64904465
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$131.25 |
| Max. Negotiated Rate |
$300.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$206.25
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$187.50
|
| Rate for Payer: Aetna Government |
$187.50
|
| Rate for Payer: Brighton Health Commercial |
$281.25
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$300.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$255.00
|
| Rate for Payer: Group Health Inc Commercial |
$187.50
|
| Rate for Payer: Group Health Inc Medicare |
$131.25
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$187.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$187.50
|
|
|
CLOTH,SKIN PREP,PREOP,2CHG
|
Facility
|
OP
|
$13.79
|
|
| Hospital Charge Code |
64903426
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$4.83 |
| Max. Negotiated Rate |
$11.03 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$7.58
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$6.90
|
| Rate for Payer: Aetna Government |
$6.90
|
| Rate for Payer: Brighton Health Commercial |
$10.34
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$11.03
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$9.38
|
| Rate for Payer: Group Health Inc Commercial |
$6.90
|
| Rate for Payer: Group Health Inc Medicare |
$4.83
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$6.90
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$6.90
|
|
|
CLOTRIMAZOLE 10 MG LOZENGE
|
Facility
|
OP
|
$1.74
|
|
| Hospital Charge Code |
41651847
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$1.39 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.96
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.87
|
| Rate for Payer: Aetna Government |
$0.87
|
| Rate for Payer: Brighton Health Commercial |
$1.30
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.39
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.18
|
| Rate for Payer: Group Health Inc Commercial |
$0.87
|
| Rate for Payer: Group Health Inc Medicare |
$0.61
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.87
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.87
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.13
|
|
|
CLOTRIMAZOLE 10 MG LOZENGE
|
Facility
|
OP
|
$1.74
|
|
| Hospital Charge Code |
41641847
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$1.39 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.96
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.87
|
| Rate for Payer: Aetna Government |
$0.87
|
| Rate for Payer: Brighton Health Commercial |
$1.30
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.39
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.18
|
| Rate for Payer: Group Health Inc Commercial |
$0.87
|
| Rate for Payer: Group Health Inc Medicare |
$0.61
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.87
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.87
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.13
|
|
|
CLOTRIMAZOLE 10 MG MT TROC [9644]
|
Facility
|
OP
|
$1.61
|
|
|
Service Code
|
NDC 00574010770
|
| Hospital Charge Code |
00574010770
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$1.29 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.88
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.80
|
| Rate for Payer: Aetna Government |
$0.80
|
| Rate for Payer: Brighton Health Commercial |
$1.21
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.29
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.09
|
| Rate for Payer: Group Health Inc Commercial |
$0.80
|
| Rate for Payer: Group Health Inc Medicare |
$0.56
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.80
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.80
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.05
|
|
|
CLOTRIMAZOLE 1% CREAM 15 GRAMS
|
Facility
|
OP
|
$3.00
|
|
| Hospital Charge Code |
41650030
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.05 |
| Max. Negotiated Rate |
$2.40 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.65
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.50
|
| Rate for Payer: Aetna Government |
$1.50
|
| Rate for Payer: Brighton Health Commercial |
$2.25
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2.40
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2.04
|
| Rate for Payer: Group Health Inc Commercial |
$1.50
|
| Rate for Payer: Group Health Inc Medicare |
$1.05
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.95
|
|
|
CLOTRIMAZOLE 1% CREAM 15 GRAMS
|
Facility
|
OP
|
$3.00
|
|
| Hospital Charge Code |
41640030
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.05 |
| Max. Negotiated Rate |
$2.40 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.65
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.50
|
| Rate for Payer: Aetna Government |
$1.50
|
| Rate for Payer: Brighton Health Commercial |
$2.25
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2.40
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2.04
|
| Rate for Payer: Group Health Inc Commercial |
$1.50
|
| Rate for Payer: Group Health Inc Medicare |
$1.05
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.95
|
|
|
CLOTRIMAZOLE 1 % EX CREA [1767]
|
Facility
|
OP
|
$1.16
|
|
|
Service Code
|
NDC 51672127502
|
| Hospital Charge Code |
51672127502
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.64
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.58
|
| Rate for Payer: Aetna Government |
$0.58
|
| Rate for Payer: Brighton Health Commercial |
$0.87
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.93
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.79
|
| Rate for Payer: Group Health Inc Commercial |
$0.58
|
| Rate for Payer: Group Health Inc Medicare |
$0.41
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.58
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.58
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.76
|
|
|
CLOTRIMAZOLE 1 % EX CREA [1767]
|
Facility
|
OP
|
$0.29
|
|
|
Service Code
|
NDC 45802043411
|
| Hospital Charge Code |
45802043411
|
|
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 |
$0.21
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.23
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.19
|
| 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
|
|
|
CLOTRIMAZOLE 1 % EX CREA [1767]
|
Facility
|
OP
|
$1.33
|
|
|
Service Code
|
NDC 51672127501
|
| Hospital Charge Code |
51672127501
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.47 |
| Max. Negotiated Rate |
$1.06 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.73
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.66
|
| Rate for Payer: Aetna Government |
$0.66
|
| Rate for Payer: Brighton Health Commercial |
$1.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.06
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.90
|
| Rate for Payer: Group Health Inc Commercial |
$0.66
|
| Rate for Payer: Group Health Inc Medicare |
$0.47
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.66
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.66
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.86
|
|
|
CLOTRIMAZOLE 1 % EX CREA [1767]
|
Facility
|
OP
|
$1.16
|
|
|
Service Code
|
NDC 68462018135
|
| Hospital Charge Code |
68462018135
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.64
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.58
|
| Rate for Payer: Aetna Government |
$0.58
|
| Rate for Payer: Brighton Health Commercial |
$0.87
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.93
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.79
|
| Rate for Payer: Group Health Inc Commercial |
$0.58
|
| Rate for Payer: Group Health Inc Medicare |
$0.41
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.58
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.58
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.75
|
|
|
CLOTRIMAZOLE 1 % EX CREA [1767]
|
Facility
|
OP
|
$0.40
|
|
|
Service Code
|
NDC 45802043401
|
| Hospital Charge Code |
45802043401
|
|
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
|
|
|
CLOTRIMAZOLE 1 % EX CREA [1767]
|
Facility
|
OP
|
$0.09
|
|
|
Service Code
|
NDC 00536127222
|
| Hospital Charge Code |
00536127222
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.05
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.04
|
| Rate for Payer: Aetna Government |
$0.04
|
| Rate for Payer: Brighton Health Commercial |
$0.06
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.07
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.06
|
| Rate for Payer: Group Health Inc Commercial |
$0.04
|
| Rate for Payer: Group Health Inc Medicare |
$0.03
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.04
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.04
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.06
|
|
|
CLOTRIMAZOLE 1 % EX CREA [1767]
|
Facility
|
OP
|
$0.57
|
|
|
Service Code
|
NDC 51672200201
|
| Hospital Charge Code |
51672200201
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.45 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.31
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.28
|
| Rate for Payer: Aetna Government |
$0.28
|
| Rate for Payer: Brighton Health Commercial |
$0.43
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.45
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.39
|
| Rate for Payer: Group Health Inc Commercial |
$0.28
|
| Rate for Payer: Group Health Inc Medicare |
$0.20
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.28
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.28
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.37
|
|
|
CLOTRIMAZOLE 1 % EX SOLN [1768]
|
Facility
|
OP
|
$3.61
|
|
|
Service Code
|
NDC 00536118170
|
| Hospital Charge Code |
00536118170
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.26 |
| Max. Negotiated Rate |
$2.88 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.98
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.80
|
| Rate for Payer: Aetna Government |
$1.80
|
| Rate for Payer: Brighton Health Commercial |
$2.70
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2.88
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2.45
|
| Rate for Payer: Group Health Inc Commercial |
$1.80
|
| Rate for Payer: Group Health Inc Medicare |
$1.26
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.80
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.80
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2.34
|
|
|
CLOTRIMAZOLE 1% SOLN 10 ML
|
Facility
|
OP
|
$5.02
|
|
| Hospital Charge Code |
41643389
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.76 |
| Max. Negotiated Rate |
$4.02 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2.76
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.51
|
| Rate for Payer: Aetna Government |
$2.51
|
| Rate for Payer: Brighton Health Commercial |
$3.76
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$4.02
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$3.41
|
| Rate for Payer: Group Health Inc Commercial |
$2.51
|
| Rate for Payer: Group Health Inc Medicare |
$1.76
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.51
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2.51
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3.26
|
|
|
CLOTRIMAZOLE 1% SOLN 10 ML
|
Facility
|
OP
|
$5.02
|
|
| Hospital Charge Code |
41653389
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.76 |
| Max. Negotiated Rate |
$4.02 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2.76
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.51
|
| Rate for Payer: Aetna Government |
$2.51
|
| Rate for Payer: Brighton Health Commercial |
$3.76
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$4.02
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$3.41
|
| Rate for Payer: Group Health Inc Commercial |
$2.51
|
| Rate for Payer: Group Health Inc Medicare |
$1.76
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.51
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2.51
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3.26
|
|
|
CLOTRIMAZOLE 1 % VA CREA [1769]
|
Facility
|
OP
|
$0.11
|
|
|
Service Code
|
NDC 61269022041
|
| Hospital Charge Code |
61269022041
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.09 |
| 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 |
$0.09
|
| 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
|
|
|
CLOTRIMAZOLE 1 % VA CREA [1769]
|
Facility
|
OP
|
$0.18
|
|
|
Service Code
|
NDC 51672200306
|
| Hospital Charge Code |
51672200306
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.10
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.09
|
| Rate for Payer: Aetna Government |
$0.09
|
| Rate for Payer: Brighton Health Commercial |
$0.13
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.14
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.12
|
| Rate for Payer: Group Health Inc Commercial |
$0.09
|
| Rate for Payer: Group Health Inc Medicare |
$0.06
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.09
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.09
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.12
|
|
|
CLOTRIMAZOLE 1 % VA CREA [1769]
|
Facility
|
OP
|
$0.11
|
|
|
Service Code
|
NDC 61269022063
|
| Hospital Charge Code |
61269022063
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.09 |
| 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 |
$0.09
|
| 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
|
|
|
CLOTRIMAZOLE 1% VAGINAL CREAM 45 GRAMS
|
Facility
|
OP
|
$5.00
|
|
| Hospital Charge Code |
41640717
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.75 |
| Max. Negotiated Rate |
$4.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2.75
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.50
|
| Rate for Payer: Aetna Government |
$2.50
|
| Rate for Payer: Brighton Health Commercial |
$3.75
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$4.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$3.40
|
| Rate for Payer: Group Health Inc Commercial |
$2.50
|
| Rate for Payer: Group Health Inc Medicare |
$1.75
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3.25
|
|
