|
BENZOCAINE-MENTHOL 20-0.5 % EX AERO
|
Facility
|
IP
|
$0.08
|
|
|
Service Code
|
NDC 5140900722
|
| Hospital Charge Code |
5140900722
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.04
|
|
|
BENZOYL PEROXIDE 5 % EX GEL
|
Facility
|
IP
|
$0.13
|
|
|
Service Code
|
NDC 0536105556
|
| Hospital Charge Code |
0536105556
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.07
|
|
|
BENZOYL PEROXIDE 5 % EX GEL
|
Facility
|
OP
|
$0.13
|
|
|
Service Code
|
NDC 0536105556
|
| Hospital Charge Code |
0536105556
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.07
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.07
|
| Rate for Payer: Aetna Government |
$0.07
|
| Rate for Payer: Brighton Health Commercial |
$0.10
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.11
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.09
|
| Rate for Payer: EmblemHealth Commercial |
$0.07
|
| Rate for Payer: Group Health Inc Commercial |
$0.07
|
| Rate for Payer: Group Health Inc Medicare |
$0.05
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.07
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.07
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.09
|
|
|
BENZTROPINE MESYLATE 0.5 MG PO TABS
|
Facility
|
IP
|
$0.59
|
|
|
Service Code
|
NDC 6808438111
|
| Hospital Charge Code |
6808438111
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$0.30 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.30
|
|
|
BENZTROPINE MESYLATE 0.5 MG PO TABS
|
Facility
|
OP
|
$0.53
|
|
|
Service Code
|
NDC 0904728861
|
| Hospital Charge Code |
0904728861
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.42 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.29
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.27
|
| Rate for Payer: Aetna Government |
$0.27
|
| Rate for Payer: Brighton Health Commercial |
$0.40
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.42
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.36
|
| Rate for Payer: EmblemHealth Commercial |
$0.27
|
| Rate for Payer: Group Health Inc Commercial |
$0.27
|
| Rate for Payer: Group Health Inc Medicare |
$0.19
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.27
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.27
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.35
|
|
|
BENZTROPINE MESYLATE 0.5 MG PO TABS
|
Facility
|
OP
|
$0.59
|
|
|
Service Code
|
NDC 6808438111
|
| Hospital Charge Code |
6808438111
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.47 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.32
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.30
|
| Rate for Payer: Aetna Government |
$0.30
|
| Rate for Payer: Brighton Health Commercial |
$0.44
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.47
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.40
|
| Rate for Payer: EmblemHealth Commercial |
$0.30
|
| Rate for Payer: Group Health Inc Commercial |
$0.30
|
| Rate for Payer: Group Health Inc Medicare |
$0.21
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.30
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.30
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.38
|
|
|
BENZTROPINE MESYLATE 0.5 MG PO TABS
|
Facility
|
IP
|
$0.53
|
|
|
Service Code
|
NDC 0904728861
|
| Hospital Charge Code |
0904728861
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$0.27 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.27
|
|
|
BENZTROPINE MESYLATE 1 MG/ML IJ SOLN
|
Facility
|
OP
|
$29.38
|
|
|
Service Code
|
HCPCS J0515
|
| Hospital Charge Code |
6838286002
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.28 |
| Max. Negotiated Rate |
$23.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$16.16
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$19.51
|
| Rate for Payer: Aetna Government |
$19.51
|
| Rate for Payer: Brighton Health Commercial |
$22.03
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$23.50
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$19.98
|
| Rate for Payer: EmblemHealth Commercial |
$14.69
|
| Rate for Payer: Group Health Inc Commercial |
$14.69
|
| Rate for Payer: Group Health Inc Medicare |
$10.28
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$14.69
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$14.69
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$15.33
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$19.09
|
|
|
BENZTROPINE MESYLATE 1 MG/ML IJ SOLN
|
Facility
|
IP
|
$29.38
|
|
|
Service Code
|
HCPCS J0515
|
| Hospital Charge Code |
6838286002
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.69 |
| Max. Negotiated Rate |
$14.69 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$14.69
|
|
|
BENZTROPINE MESYLATE 1 MG/ML IJ SOLN
|
Facility
|
OP
|
$27.00
|
|
|
Service Code
|
HCPCS J0515
|
| Hospital Charge Code |
0143923301
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.45 |
| Max. Negotiated Rate |
$21.60 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$14.85
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$19.51
|
| Rate for Payer: Aetna Government |
$19.51
|
| Rate for Payer: Brighton Health Commercial |
$20.25
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$21.60
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$18.36
|
| Rate for Payer: EmblemHealth Commercial |
$13.50
|
| Rate for Payer: Group Health Inc Commercial |
$13.50
|
| Rate for Payer: Group Health Inc Medicare |
$9.45
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$13.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$13.50
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$15.33
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$17.55
|
|
|
BENZTROPINE MESYLATE 1 MG/ML IJ SOLN
|
Facility
|
OP
|
$29.38
|
|
|
Service Code
|
HCPCS J0515
|
| Hospital Charge Code |
6838286010
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.28 |
| Max. Negotiated Rate |
$23.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$16.16
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$19.51
|
| Rate for Payer: Aetna Government |
$19.51
|
| Rate for Payer: Brighton Health Commercial |
$22.03
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$23.50
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$19.98
|
| Rate for Payer: EmblemHealth Commercial |
$14.69
|
| Rate for Payer: Group Health Inc Commercial |
$14.69
|
| Rate for Payer: Group Health Inc Medicare |
$10.28
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$14.69
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$14.69
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$15.33
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$19.09
|
|
|
BENZTROPINE MESYLATE 1 MG/ML IJ SOLN
|
Facility
|
IP
|
$29.38
|
|
|
Service Code
|
HCPCS J0515
|
| Hospital Charge Code |
6838286010
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.69 |
| Max. Negotiated Rate |
$14.69 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$14.69
|
|
|
BENZTROPINE MESYLATE 1 MG/ML IJ SOLN
|
Facility
|
IP
|
$27.00
|
|
|
Service Code
|
HCPCS J0515
|
| Hospital Charge Code |
0143923301
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.50 |
| Max. Negotiated Rate |
$13.50 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$13.50
|
|
|
BENZTROPINE MESYLATE 1 MG PO TABS
|
Facility
|
OP
|
$0.59
|
|
|
Service Code
|
NDC 6808438811
|
| Hospital Charge Code |
6808438811
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.47 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.32
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.30
|
| Rate for Payer: Aetna Government |
$0.30
|
| Rate for Payer: Brighton Health Commercial |
$0.44
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.47
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.40
|
| Rate for Payer: EmblemHealth Commercial |
$0.30
|
| Rate for Payer: Group Health Inc Commercial |
$0.30
|
| Rate for Payer: Group Health Inc Medicare |
$0.21
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.30
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.30
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.38
|
|
|
BENZTROPINE MESYLATE 1 MG PO TABS
|
Facility
|
IP
|
$0.59
|
|
|
Service Code
|
NDC 6808438811
|
| Hospital Charge Code |
6808438811
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$0.30 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.30
|
|
|
BENZTROPINE MESYLATE 1 MG PO TABS
|
Facility
|
IP
|
$0.57
|
|
|
Service Code
|
NDC 0904728961
|
| Hospital Charge Code |
0904728961
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$0.28 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.28
|
|
|
BENZTROPINE MESYLATE 1 MG PO TABS
|
Facility
|
OP
|
$0.41
|
|
|
Service Code
|
NDC 6931513701
|
| Hospital Charge Code |
6931513701
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.33 |
| 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 |
$0.31
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.33
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.28
|
| Rate for Payer: EmblemHealth Commercial |
$0.20
|
| 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 |
$0.27
|
|
|
BENZTROPINE MESYLATE 1 MG PO TABS
|
Facility
|
IP
|
$0.41
|
|
|
Service Code
|
NDC 6931513701
|
| Hospital Charge Code |
6931513701
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.20
|
|
|
BENZTROPINE MESYLATE 1 MG PO TABS
|
Facility
|
OP
|
$0.57
|
|
|
Service Code
|
NDC 0904728961
|
| Hospital Charge Code |
0904728961
|
|
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: EmblemHealth Commercial |
$0.28
|
| 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
|
|
|
BENZTROPINE MESYLATE 2 MG PO TABS
|
Facility
|
IP
|
$0.70
|
|
|
Service Code
|
NDC 0904678961
|
| Hospital Charge Code |
0904678961
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$0.35 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.35
|
|
|
BENZTROPINE MESYLATE 2 MG PO TABS
|
Facility
|
IP
|
$0.52
|
|
|
Service Code
|
NDC 6909783207
|
| Hospital Charge Code |
6909783207
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.26
|
|
|
BENZTROPINE MESYLATE 2 MG PO TABS
|
Facility
|
IP
|
$0.52
|
|
|
Service Code
|
NDC 0603243921
|
| Hospital Charge Code |
0603243921
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.26
|
|
|
BENZTROPINE MESYLATE 2 MG PO TABS
|
Facility
|
OP
|
$0.70
|
|
|
Service Code
|
NDC 0904678961
|
| Hospital Charge Code |
0904678961
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$0.56 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.39
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.35
|
| Rate for Payer: Aetna Government |
$0.35
|
| Rate for Payer: Brighton Health Commercial |
$0.53
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.56
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.48
|
| Rate for Payer: EmblemHealth Commercial |
$0.35
|
| Rate for Payer: Group Health Inc Commercial |
$0.35
|
| Rate for Payer: Group Health Inc Medicare |
$0.25
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.35
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.35
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.46
|
|
|
BENZTROPINE MESYLATE 2 MG PO TABS
|
Facility
|
OP
|
$0.52
|
|
|
Service Code
|
NDC 6909783207
|
| Hospital Charge Code |
6909783207
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.42 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.29
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.26
|
| Rate for Payer: Aetna Government |
$0.26
|
| Rate for Payer: Brighton Health Commercial |
$0.39
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.42
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.35
|
| Rate for Payer: EmblemHealth Commercial |
$0.26
|
| Rate for Payer: Group Health Inc Commercial |
$0.26
|
| Rate for Payer: Group Health Inc Medicare |
$0.18
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.26
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.26
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.34
|
|
|
BENZTROPINE MESYLATE 2 MG PO TABS
|
Facility
|
OP
|
$0.52
|
|
|
Service Code
|
NDC 0603243921
|
| Hospital Charge Code |
0603243921
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.42 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.29
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.26
|
| Rate for Payer: Aetna Government |
$0.26
|
| Rate for Payer: Brighton Health Commercial |
$0.39
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.42
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.35
|
| Rate for Payer: EmblemHealth Commercial |
$0.26
|
| Rate for Payer: Group Health Inc Commercial |
$0.26
|
| Rate for Payer: Group Health Inc Medicare |
$0.18
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.26
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.26
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.34
|
|
