|
DILTIAZEM 90 MG TAB
|
Facility
OP
|
$1.00
|
|
| Hospital Charge Code |
41650647
|
|
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: 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
|
|
|
DILTIAZEM 90 MG TAB
|
Facility
OP
|
$1.00
|
|
| Hospital Charge Code |
41640647
|
|
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: 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
|
|
|
DILUTE RUSSELL'S VIPER VENOM
|
Facility
OP
|
$23.95
|
|
|
Service Code
|
HCPCS 85613
|
| Hospital Charge Code |
40629221
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$7.66 |
| Max. Negotiated Rate |
$15.22 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$13.17
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$9.58
|
| Rate for Payer: Aetna Government |
$9.58
|
| Rate for Payer: Cash Price |
$9.58
|
| Rate for Payer: Cash Price |
$9.58
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$9.58
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$15.22
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$12.88
|
| Rate for Payer: Elderplan Medicare Advantage |
$9.58
|
| Rate for Payer: EmblemHealth Commercial |
$9.58
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$8.62
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$8.14
|
| Rate for Payer: Fidelis Essential Plan QHP |
$8.53
|
| Rate for Payer: Fidelis Medicare Advantage |
$9.58
|
| Rate for Payer: Fidelis Qualified Health Plan |
$8.53
|
| Rate for Payer: Group Health Inc Commercial |
$9.58
|
| Rate for Payer: Group Health Inc Medicare |
$9.58
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$11.98
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$9.58
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$9.58
|
| Rate for Payer: Healthfirst Medicare Advantage |
$9.58
|
| Rate for Payer: Healthfirst QHP |
$9.58
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$9.58
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$9.58
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$7.66
|
| Rate for Payer: Wellcare Medicare |
$8.62
|
|
|
DIMENHYDRINATE 50 MG TAB
|
Facility
OP
|
$1.00
|
|
| Hospital Charge Code |
41643380
|
|
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: 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
|
|
|
DIMENHYDRINATE 50 MG TAB
|
Facility
OP
|
$1.00
|
|
| Hospital Charge Code |
41653380
|
|
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: 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
|
|
|
DIMERCAPROL 100 MG/ML 3 ML
|
Facility
OP
|
$54.29
|
|
|
Service Code
|
HCPCS J0470
|
| Hospital Charge Code |
41642577
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$27.14 |
| Max. Negotiated Rate |
$62.80 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$29.86
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$59.81
|
| Rate for Payer: Aetna Government |
$59.81
|
| Rate for Payer: Cash Price |
$59.81
|
| Rate for Payer: Cash Price |
$59.81
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$59.81
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$27.14
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$31.22
|
| Rate for Payer: Elderplan Medicare Advantage |
$59.81
|
| Rate for Payer: EmblemHealth Commercial |
$59.81
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$59.81
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$59.81
|
| Rate for Payer: Fidelis Essential Plan QHP |
$62.80
|
| Rate for Payer: Fidelis Medicare Advantage |
$59.81
|
| Rate for Payer: Fidelis Qualified Health Plan |
$62.80
|
| Rate for Payer: Group Health Inc Commercial |
$59.81
|
| Rate for Payer: Group Health Inc Medicare |
$59.81
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$27.14
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$27.14
|
| Rate for Payer: Healthfirst Medicare Advantage |
$50.84
|
| Rate for Payer: Healthfirst QHP |
$59.81
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$59.81
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$35.29
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$47.85
|
| Rate for Payer: Wellcare Medicare |
$56.82
|
|
|
DIMERCAPROL 100 MG/ML 3 ML
|
Facility
IP
|
$54.29
|
|
|
Service Code
|
HCPCS J0470
|
| Hospital Charge Code |
41642577
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$27.14 |
| Max. Negotiated Rate |
$27.14 |
| Rate for Payer: Cash Price |
$59.81
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$27.14
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$27.14
|
|
|
DIMERCAPROL 300 MG/ML INJ
|
Facility
OP
|
$54.29
|
|
|
Service Code
|
HCPCS J0470
|
| Hospital Charge Code |
41652577
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$27.14 |
| Max. Negotiated Rate |
$62.80 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$29.86
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$59.81
|
| Rate for Payer: Aetna Government |
$59.81
|
| Rate for Payer: Cash Price |
$59.81
|
| Rate for Payer: Cash Price |
$59.81
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$59.81
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$27.14
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$31.22
|
| Rate for Payer: Elderplan Medicare Advantage |
$59.81
|
| Rate for Payer: EmblemHealth Commercial |
$59.81
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$59.81
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$59.81
|
| Rate for Payer: Fidelis Essential Plan QHP |
$62.80
|
| Rate for Payer: Fidelis Medicare Advantage |
$59.81
|
| Rate for Payer: Fidelis Qualified Health Plan |
$62.80
|
| Rate for Payer: Group Health Inc Commercial |
$59.81
|
| Rate for Payer: Group Health Inc Medicare |
$59.81
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$27.14
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$27.14
|
| Rate for Payer: Healthfirst Medicare Advantage |
$50.84
|
| Rate for Payer: Healthfirst QHP |
$59.81
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$59.81
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$35.29
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$47.85
|
| Rate for Payer: Wellcare Medicare |
$56.82
|
|
|
DIMERCAPROL 300 MG/ML INJ
|
Facility
IP
|
$54.29
|
|
|
Service Code
|
HCPCS J0470
|
| Hospital Charge Code |
41652577
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$27.14 |
| Max. Negotiated Rate |
$27.14 |
| Rate for Payer: Cash Price |
$59.81
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$27.14
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$27.14
|
|
|
DIMETHYL SULFOXIDE 50% SOLN
|
Facility
IP
|
$170.52
|
|
|
Service Code
|
HCPCS J1212
|
| Hospital Charge Code |
41644799
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$85.26 |
| Max. Negotiated Rate |
$85.26 |
| Rate for Payer: Cash Price |
$680.82
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$85.26
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$85.26
|
|
|
DIMETHYL SULFOXIDE 50% SOLN
|
Facility
IP
|
$170.52
|
|
|
Service Code
|
HCPCS J1212
|
| Hospital Charge Code |
41654799
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$85.26 |
| Max. Negotiated Rate |
$85.26 |
| Rate for Payer: Cash Price |
$680.82
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$85.26
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$85.26
|
|
|
DIMETHYL SULFOXIDE 50% SOLN
|
Facility
OP
|
$170.52
|
|
|
Service Code
|
HCPCS J1212
|
| Hospital Charge Code |
41644799
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$85.26 |
| Max. Negotiated Rate |
$720.97 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$93.79
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$680.82
|
| Rate for Payer: Aetna Government |
$680.82
|
| Rate for Payer: Cash Price |
$680.82
|
| Rate for Payer: Cash Price |
$680.82
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$680.82
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$85.26
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$98.05
|
| Rate for Payer: Elderplan Medicare Advantage |
$680.82
|
| Rate for Payer: EmblemHealth Commercial |
$680.82
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$680.82
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$680.82
|
| Rate for Payer: Fidelis Essential Plan QHP |
$714.86
|
| Rate for Payer: Fidelis Medicare Advantage |
$680.82
|
| Rate for Payer: Fidelis Qualified Health Plan |
$714.86
|
| Rate for Payer: Group Health Inc Commercial |
$680.82
|
| Rate for Payer: Group Health Inc Medicare |
$680.82
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$85.26
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$85.26
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$682.52
|
| Rate for Payer: Healthfirst Medicare Advantage |
$578.70
|
| Rate for Payer: Healthfirst QHP |
$680.82
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$680.82
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$720.97
|
| Rate for Payer: SOMOS Essential |
$720.97
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$110.84
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$544.66
|
| Rate for Payer: Wellcare Medicare |
$646.78
|
|
|
DIMETHYL SULFOXIDE 50% SOLN
|
Facility
OP
|
$170.52
|
|
|
Service Code
|
HCPCS J1212
|
| Hospital Charge Code |
41654799
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$85.26 |
| Max. Negotiated Rate |
$720.97 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$93.79
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$680.82
|
| Rate for Payer: Aetna Government |
$680.82
|
| Rate for Payer: Cash Price |
$680.82
|
| Rate for Payer: Cash Price |
$680.82
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$680.82
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$85.26
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$98.05
|
| Rate for Payer: Elderplan Medicare Advantage |
$680.82
|
| Rate for Payer: EmblemHealth Commercial |
$680.82
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$680.82
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$680.82
|
| Rate for Payer: Fidelis Essential Plan QHP |
$714.86
|
| Rate for Payer: Fidelis Medicare Advantage |
$680.82
|
| Rate for Payer: Fidelis Qualified Health Plan |
$714.86
|
| Rate for Payer: Group Health Inc Commercial |
$680.82
|
| Rate for Payer: Group Health Inc Medicare |
$680.82
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$85.26
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$85.26
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$682.52
|
| Rate for Payer: Healthfirst Medicare Advantage |
$578.70
|
| Rate for Payer: Healthfirst QHP |
$680.82
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$680.82
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$720.97
|
| Rate for Payer: SOMOS Essential |
$720.97
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$110.84
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$544.66
|
| Rate for Payer: Wellcare Medicare |
$646.78
|
|
|
DINOPROSTONE 10MG VAG INSERT
|
Facility
OP
|
$411.82
|
|
| Hospital Charge Code |
41641413
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$144.14 |
| Max. Negotiated Rate |
$329.46 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$226.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$205.91
|
| Rate for Payer: Aetna Government |
$205.91
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$329.46
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$280.04
|
| Rate for Payer: Group Health Inc Commercial |
$205.91
|
| Rate for Payer: Group Health Inc Medicare |
$144.14
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$205.91
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$205.91
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$267.68
|
|
|
DINOPROSTONE 10MG VAG INSERT
|
Facility
OP
|
$411.82
|
|
| Hospital Charge Code |
41651413
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$144.14 |
| Max. Negotiated Rate |
$329.46 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$226.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$205.91
|
| Rate for Payer: Aetna Government |
$205.91
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$329.46
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$280.04
|
| Rate for Payer: Group Health Inc Commercial |
$205.91
|
| Rate for Payer: Group Health Inc Medicare |
$144.14
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$205.91
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$205.91
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$267.68
|
|
|
DINOPROSTONE 20 MG VAG SUPP
|
Facility
OP
|
$1,785.00
|
|
| Hospital Charge Code |
41654120
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$624.75 |
| Max. Negotiated Rate |
$1,428.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$981.75
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$892.50
|
| Rate for Payer: Aetna Government |
$892.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,428.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,213.80
|
| Rate for Payer: Group Health Inc Commercial |
$892.50
|
| Rate for Payer: Group Health Inc Medicare |
$624.75
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$892.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$892.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,160.25
|
|
|
DINOPROSTONE 20 MG VAG SUPP
|
Facility
OP
|
$1,785.00
|
|
| Hospital Charge Code |
41644120
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$624.75 |
| Max. Negotiated Rate |
$1,428.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$981.75
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$892.50
|
| Rate for Payer: Aetna Government |
$892.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,428.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,213.80
|
| Rate for Payer: Group Health Inc Commercial |
$892.50
|
| Rate for Payer: Group Health Inc Medicare |
$624.75
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$892.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$892.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,160.25
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ELIXIR UDC
|
Facility
OP
|
$2.80
|
|
|
Service Code
|
HCPCS Q0163
|
| Hospital Charge Code |
41653474
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$1.82 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.54
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.01
|
| Rate for Payer: Aetna Government |
$0.01
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.40
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.61
|
| Rate for Payer: Group Health Inc Commercial |
$1.40
|
| Rate for Payer: Group Health Inc Medicare |
$0.98
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.40
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.40
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.82
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ELIXIR UDC
|
Facility
IP
|
$2.80
|
|
|
Service Code
|
HCPCS Q0163
|
| Hospital Charge Code |
41653474
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.40 |
| Max. Negotiated Rate |
$1.40 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.40
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.40
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ELIXIR UDC
|
Facility
IP
|
$2.80
|
|
|
Service Code
|
HCPCS Q0163
|
| Hospital Charge Code |
41643474
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.40 |
| Max. Negotiated Rate |
$1.40 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.40
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.40
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ELIXIR UDC
|
Facility
OP
|
$2.80
|
|
|
Service Code
|
HCPCS Q0163
|
| Hospital Charge Code |
41643474
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$1.82 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.54
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.01
|
| Rate for Payer: Aetna Government |
$0.01
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.40
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.61
|
| Rate for Payer: Group Health Inc Commercial |
$1.40
|
| Rate for Payer: Group Health Inc Medicare |
$0.98
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.40
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.40
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.82
|
|
|
DIPHENHYDRAMINE 25 MG/10 ML ELIXIR UDC
|
Facility
IP
|
$1.56
|
|
|
Service Code
|
HCPCS Q0163
|
| Hospital Charge Code |
41653475
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.78 |
| Max. Negotiated Rate |
$0.78 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.78
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.78
|
|
|
DIPHENHYDRAMINE 25 MG/10 ML ELIXIR UDC
|
Facility
OP
|
$1.56
|
|
|
Service Code
|
HCPCS Q0163
|
| Hospital Charge Code |
41653475
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$1.01 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.86
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.01
|
| Rate for Payer: Aetna Government |
$0.01
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.78
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.90
|
| Rate for Payer: Group Health Inc Commercial |
$0.78
|
| Rate for Payer: Group Health Inc Medicare |
$0.55
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.78
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.78
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.01
|
|
|
DIPHENHYDRAMINE 25 MG/10 ML ELIXIR UDC
|
Facility
IP
|
$1.56
|
|
|
Service Code
|
HCPCS Q0163
|
| Hospital Charge Code |
41643475
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.78 |
| Max. Negotiated Rate |
$0.78 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.78
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.78
|
|
|
DIPHENHYDRAMINE 25 MG/10 ML ELIXIR UDC
|
Facility
OP
|
$1.56
|
|
|
Service Code
|
HCPCS Q0163
|
| Hospital Charge Code |
41643475
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$1.01 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.86
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.01
|
| Rate for Payer: Aetna Government |
$0.01
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.78
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.90
|
| Rate for Payer: Group Health Inc Commercial |
$0.78
|
| Rate for Payer: Group Health Inc Medicare |
$0.55
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.78
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.78
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.01
|
|
