|
DOCETAXEL 80 MG/2 ML INJ
|
Facility
IP
|
$9.35
|
|
|
Service Code
|
HCPCS J9171
|
| Hospital Charge Code |
41651740
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.68 |
| Max. Negotiated Rate |
$4.68 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4.68
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4.68
|
|
|
DOC PT UNABLE COMM
|
Facility
OP
|
$0.01
|
|
|
Service Code
|
HCPCS G2183
|
| Hospital Charge Code |
30300311
|
|
Hospital Revenue Code
|
929
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.01
|
| 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 |
$0.01
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.01
|
| Rate for Payer: Group Health Inc Commercial |
$0.01
|
| Rate for Payer: Group Health Inc Medicare |
$0.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.01
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.01
|
|
|
DOCUM OF VIRAL LOAD => 200COPIES
|
Facility
OP
|
$0.01
|
|
|
Service Code
|
HCPCS G9242
|
| Hospital Charge Code |
30300370
|
|
Hospital Revenue Code
|
969
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.01
|
| 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 |
$0.01
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.01
|
| Rate for Payer: Group Health Inc Commercial |
$0.01
|
| Rate for Payer: Group Health Inc Medicare |
$0.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.01
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.01
|
|
|
DOCUM OF VIRAL LOAD > 200 COPIES
|
Facility
OP
|
$0.01
|
|
|
Service Code
|
HCPCS G9243
|
| Hospital Charge Code |
30300371
|
|
Hospital Revenue Code
|
969
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.01
|
| 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 |
$0.01
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.01
|
| Rate for Payer: Group Health Inc Commercial |
$0.01
|
| Rate for Payer: Group Health Inc Medicare |
$0.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.01
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.01
|
|
|
DOCUSATE SODIUM 100 MG/10 ML LIQ
|
Facility
OP
|
$0.62
|
|
| Hospital Charge Code |
41643359
|
|
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: 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
|
|
|
DOCUSATE SODIUM 100 MG/10 ML LIQ
|
Facility
OP
|
$0.62
|
|
| Hospital Charge Code |
41653359
|
|
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: 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
|
|
|
DOCUSATE SODIUM 100MG/25ML UD LIQ
|
Facility
OP
|
$1.00
|
|
| Hospital Charge Code |
41657038
|
|
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
|
|
|
DOCUSATE SODIUM 100MG/25ML UD LIQ
|
Facility
OP
|
$1.00
|
|
| Hospital Charge Code |
41647038
|
|
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
|
|
|
DOCUSATE SODIUM 100 MG CAP
|
Facility
OP
|
$1.00
|
|
| Hospital Charge Code |
41640034
|
|
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
|
|
|
DOCUSATE SODIUM 100 MG CAP
|
Facility
OP
|
$1.00
|
|
| Hospital Charge Code |
41650034
|
|
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
|
|
|
DOLUTEGRAVIR 50MG TAB
|
Facility
OP
|
$59.30
|
|
| Hospital Charge Code |
41645861
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$20.76 |
| Max. Negotiated Rate |
$47.44 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$32.62
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$29.65
|
| Rate for Payer: Aetna Government |
$29.65
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$47.44
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$40.32
|
| Rate for Payer: Group Health Inc Commercial |
$29.65
|
| Rate for Payer: Group Health Inc Medicare |
$20.76
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$29.65
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$29.65
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$38.54
|
|
|
DOLUTEGRAVIR 50MG TAB
|
Facility
OP
|
$59.30
|
|
| Hospital Charge Code |
41655861
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$20.76 |
| Max. Negotiated Rate |
$47.44 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$32.62
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$29.65
|
| Rate for Payer: Aetna Government |
$29.65
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$47.44
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$40.32
|
| Rate for Payer: Group Health Inc Commercial |
$29.65
|
| Rate for Payer: Group Health Inc Medicare |
$20.76
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$29.65
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$29.65
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$38.54
|
|
|
DOLUTEGRAVIR/RILPIVIRINE 50-25MG
|
Facility
OP
|
$225.43
|
|
| Hospital Charge Code |
41658890
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$78.90 |
| Max. Negotiated Rate |
$180.34 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$123.99
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$112.72
|
| Rate for Payer: Aetna Government |
$112.72
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$180.34
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$153.29
|
| Rate for Payer: Group Health Inc Commercial |
$112.72
|
| Rate for Payer: Group Health Inc Medicare |
$78.90
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$112.72
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$112.72
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$146.53
|
|
|
DOLUTEGRAVIR/RILPIVIRINE 50-25MG
|
Facility
OP
|
$225.43
|
|
| Hospital Charge Code |
41648890
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$78.90 |
| Max. Negotiated Rate |
$180.34 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$123.99
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$112.72
|
| Rate for Payer: Aetna Government |
$112.72
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$180.34
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$153.29
|
| Rate for Payer: Group Health Inc Commercial |
$112.72
|
| Rate for Payer: Group Health Inc Medicare |
$78.90
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$112.72
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$112.72
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$146.53
|
|
|
DOME PASTE BANDAGE 3 INCH DRESSING
|
Facility
OP
|
$14.00
|
|
| Hospital Charge Code |
41650109
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.90 |
| Max. Negotiated Rate |
$11.20 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$7.70
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$7.00
|
| Rate for Payer: Aetna Government |
$7.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$11.20
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$9.52
|
| Rate for Payer: Group Health Inc Commercial |
$7.00
|
| Rate for Payer: Group Health Inc Medicare |
$4.90
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$7.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$7.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$9.10
|
|
|
DOME PASTE BANDAGE 3 INCH DRESSING
|
Facility
OP
|
$14.00
|
|
| Hospital Charge Code |
41640109
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.90 |
| Max. Negotiated Rate |
$11.20 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$7.70
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$7.00
|
| Rate for Payer: Aetna Government |
$7.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$11.20
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$9.52
|
| Rate for Payer: Group Health Inc Commercial |
$7.00
|
| Rate for Payer: Group Health Inc Medicare |
$4.90
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$7.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$7.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$9.10
|
|
|
DOME PASTE BANDAGE 4 INCH DRESSING
|
Facility
OP
|
$16.00
|
|
| Hospital Charge Code |
41650108
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.60 |
| Max. Negotiated Rate |
$12.80 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$8.80
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$8.00
|
| Rate for Payer: Aetna Government |
$8.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$12.80
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$10.88
|
| Rate for Payer: Group Health Inc Commercial |
$8.00
|
| Rate for Payer: Group Health Inc Medicare |
$5.60
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$8.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$8.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$10.40
|
|
|
DOME PASTE BANDAGE 4 INCH DRESSING
|
Facility
OP
|
$16.00
|
|
| Hospital Charge Code |
41640108
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.60 |
| Max. Negotiated Rate |
$12.80 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$8.80
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$8.00
|
| Rate for Payer: Aetna Government |
$8.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$12.80
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$10.88
|
| Rate for Payer: Group Health Inc Commercial |
$8.00
|
| Rate for Payer: Group Health Inc Medicare |
$5.60
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$8.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$8.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$10.40
|
|
|
DOMES
|
Facility
OP
|
$19.14
|
|
| Hospital Charge Code |
40200680
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$6.70 |
| Max. Negotiated Rate |
$15.31 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$10.53
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$9.57
|
| Rate for Payer: Aetna Government |
$9.57
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$15.31
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$13.02
|
| Rate for Payer: Group Health Inc Commercial |
$9.57
|
| Rate for Payer: Group Health Inc Medicare |
$6.70
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$9.57
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$9.57
|
|
|
DONEPEZIL 10 MG TAB
|
Facility
OP
|
$0.23
|
|
| Hospital Charge Code |
41653124
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.13
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.12
|
| Rate for Payer: Aetna Government |
$0.12
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.18
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.16
|
| Rate for Payer: Group Health Inc Commercial |
$0.12
|
| Rate for Payer: Group Health Inc Medicare |
$0.08
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.12
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.12
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.15
|
|
|
DONEPEZIL 10 MG TAB
|
Facility
OP
|
$0.23
|
|
| Hospital Charge Code |
41643124
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.13
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.12
|
| Rate for Payer: Aetna Government |
$0.12
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.18
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.16
|
| Rate for Payer: Group Health Inc Commercial |
$0.12
|
| Rate for Payer: Group Health Inc Medicare |
$0.08
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.12
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.12
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.15
|
|
|
DONEPEZIL 5 MG TAB
|
Facility
OP
|
$0.23
|
|
| Hospital Charge Code |
41651900
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.13
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.12
|
| Rate for Payer: Aetna Government |
$0.12
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.18
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.16
|
| Rate for Payer: Group Health Inc Commercial |
$0.12
|
| Rate for Payer: Group Health Inc Medicare |
$0.08
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.12
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.12
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.15
|
|
|
DONEPEZIL 5 MG TAB
|
Facility
OP
|
$0.23
|
|
| Hospital Charge Code |
41641900
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.13
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.12
|
| Rate for Payer: Aetna Government |
$0.12
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.18
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.16
|
| Rate for Payer: Group Health Inc Commercial |
$0.12
|
| Rate for Payer: Group Health Inc Medicare |
$0.08
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.12
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.12
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.15
|
|
|
DONUT PESSARY 3, 76MM
|
Facility
OP
|
$144.83
|
|
| Hospital Charge Code |
64905203
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$50.69 |
| Max. Negotiated Rate |
$115.86 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$79.66
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$72.42
|
| Rate for Payer: Aetna Government |
$72.42
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$115.86
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$98.48
|
| Rate for Payer: Group Health Inc Commercial |
$72.42
|
| Rate for Payer: Group Health Inc Medicare |
$50.69
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$72.42
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$72.42
|
|
|
DONUT PESSARY SIZE 2
|
Facility
OP
|
$144.83
|
|
| Hospital Charge Code |
64905603
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$50.69 |
| Max. Negotiated Rate |
$115.86 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$79.66
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$72.42
|
| Rate for Payer: Aetna Government |
$72.42
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$115.86
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$98.48
|
| Rate for Payer: Group Health Inc Commercial |
$72.42
|
| Rate for Payer: Group Health Inc Medicare |
$50.69
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$72.42
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$72.42
|
|
