|
DIAZEPAM 5 MG/5 ML ELIXIR
|
Facility
|
OP
|
$4.00
|
|
| Hospital Charge Code |
41642078
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.40 |
| Max. Negotiated Rate |
$3.20 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2.20
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.00
|
| Rate for Payer: Aetna Government |
$2.00
|
| Rate for Payer: Brighton Health Commercial |
$3.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$3.20
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2.72
|
| Rate for Payer: Group Health Inc Commercial |
$2.00
|
| Rate for Payer: Group Health Inc Medicare |
$1.40
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2.60
|
|
|
DIAZEPAM 5 MG/5 ML ELIXIR
|
Facility
|
OP
|
$4.00
|
|
| Hospital Charge Code |
41652078
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.40 |
| Max. Negotiated Rate |
$3.20 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2.20
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.00
|
| Rate for Payer: Aetna Government |
$2.00
|
| Rate for Payer: Brighton Health Commercial |
$3.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$3.20
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2.72
|
| Rate for Payer: Group Health Inc Commercial |
$2.00
|
| Rate for Payer: Group Health Inc Medicare |
$1.40
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2.60
|
|
|
DIAZEPAM 5 MG/5ML PO SOLN [114047]
|
Facility
|
OP
|
$0.92
|
|
|
Service Code
|
NDC 00121090505
|
| Hospital Charge Code |
00121090505
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$0.74 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.51
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.46
|
| Rate for Payer: Aetna Government |
$0.46
|
| Rate for Payer: Brighton Health Commercial |
$0.69
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.74
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.63
|
| Rate for Payer: Group Health Inc Commercial |
$0.46
|
| Rate for Payer: Group Health Inc Medicare |
$0.32
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.46
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.46
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.60
|
|
|
DIAZEPAM 5 MG/ML IJ SOLN [2401]
|
Facility
|
OP
|
$14.77
|
|
|
Service Code
|
HCPCS J3360
|
| Hospital Charge Code |
00641624410
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.17 |
| Max. Negotiated Rate |
$11.81 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$8.12
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$5.79
|
| Rate for Payer: Aetna Government |
$5.79
|
| Rate for Payer: Brighton Health Commercial |
$11.07
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$11.81
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$10.04
|
| Rate for Payer: Group Health Inc Commercial |
$7.38
|
| Rate for Payer: Group Health Inc Medicare |
$5.17
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$7.38
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$7.38
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$6.54
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$6.93
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$6.93
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$6.93
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$9.60
|
|
|
DIAZEPAM 5 MG/ML IJ SOLN [2401]
|
Facility
|
OP
|
$14.77
|
|
|
Service Code
|
HCPCS J3360
|
| Hospital Charge Code |
69339013634
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.17 |
| Max. Negotiated Rate |
$11.82 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$8.12
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$5.79
|
| Rate for Payer: Aetna Government |
$5.79
|
| Rate for Payer: Brighton Health Commercial |
$11.08
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$11.82
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$10.04
|
| Rate for Payer: Group Health Inc Commercial |
$7.38
|
| Rate for Payer: Group Health Inc Medicare |
$5.17
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$7.38
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$7.38
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$6.54
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$6.93
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$6.93
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$6.93
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$9.60
|
|
|
DIAZEPAM 5 MG/ML IJ SOLN [2401]
|
Facility
|
OP
|
$20.20
|
|
|
Service Code
|
HCPCS J3360
|
| Hospital Charge Code |
00409127332
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.79 |
| Max. Negotiated Rate |
$16.16 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$11.11
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$5.79
|
| Rate for Payer: Aetna Government |
$5.79
|
| Rate for Payer: Brighton Health Commercial |
$15.15
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$16.16
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$13.73
|
| Rate for Payer: Group Health Inc Commercial |
$10.10
|
| Rate for Payer: Group Health Inc Medicare |
$7.07
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$10.10
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$10.10
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$6.54
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$6.93
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$6.93
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$6.93
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$13.13
|
|
|
DIAZEPAM 5 MG/ML INJ CARTRIDGE
|
Facility
|
IP
|
$2.11
|
|
| Hospital Charge Code |
41654247
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.06 |
| Max. Negotiated Rate |
$1.06 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.06
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.06
|
|
|
DIAZEPAM 5 MG/ML INJ CARTRIDGE
|
Facility
|
IP
|
$2.11
|
|
| Hospital Charge Code |
41644247
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.06 |
| Max. Negotiated Rate |
$1.06 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.06
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.06
|
|
|
DIAZEPAM 5 MG/ML INJ CARTRIDGE
|
Facility
|
OP
|
$2.11
|
|
| Hospital Charge Code |
41644247
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.74 |
| Max. Negotiated Rate |
$1.37 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.16
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.06
|
| Rate for Payer: Aetna Government |
$1.06
|
| Rate for Payer: Brighton Health Commercial |
$1.27
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.06
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.21
|
| Rate for Payer: Group Health Inc Commercial |
$1.06
|
| Rate for Payer: Group Health Inc Medicare |
$0.74
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.06
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.06
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.37
|
|
|
DIAZEPAM 5 MG/ML INJ CARTRIDGE
|
Facility
|
OP
|
$2.11
|
|
| Hospital Charge Code |
41654247
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.74 |
| Max. Negotiated Rate |
$1.37 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.16
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.06
|
| Rate for Payer: Aetna Government |
$1.06
|
| Rate for Payer: Brighton Health Commercial |
$1.27
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.06
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.21
|
| Rate for Payer: Group Health Inc Commercial |
$1.06
|
| Rate for Payer: Group Health Inc Medicare |
$0.74
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.06
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.06
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.37
|
|
|
DIAZEPAM 5 MG PO TABS [2405]
|
Facility
|
OP
|
$0.20
|
|
|
Service Code
|
NDC 00172392660
|
| Hospital Charge Code |
00172392660
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.11
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.10
|
| Rate for Payer: Aetna Government |
$0.10
|
| Rate for Payer: Brighton Health Commercial |
$0.15
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.16
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.14
|
| Rate for Payer: Group Health Inc Commercial |
$0.10
|
| Rate for Payer: Group Health Inc Medicare |
$0.07
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.10
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.10
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.13
|
|
|
DIAZEPAM 5 MG PO TABS [2405]
|
Facility
|
OP
|
$0.32
|
|
|
Service Code
|
NDC 51079028501
|
| Hospital Charge Code |
51079028501
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.18
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.16
|
| Rate for Payer: Aetna Government |
$0.16
|
| Rate for Payer: Brighton Health Commercial |
$0.24
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.26
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.22
|
| Rate for Payer: Group Health Inc Commercial |
$0.16
|
| Rate for Payer: Group Health Inc Medicare |
$0.11
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.16
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.16
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.21
|
|
|
DIAZEPAM 5 MG PO TABS [2405]
|
Facility
|
OP
|
$0.32
|
|
|
Service Code
|
NDC 51079028520
|
| Hospital Charge Code |
51079028520
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.18
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.16
|
| Rate for Payer: Aetna Government |
$0.16
|
| Rate for Payer: Brighton Health Commercial |
$0.24
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.26
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.22
|
| Rate for Payer: Group Health Inc Commercial |
$0.16
|
| Rate for Payer: Group Health Inc Medicare |
$0.11
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.16
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.16
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.21
|
|
|
DIAZEPAM 5 MG TAB
|
Facility
|
OP
|
$1.00
|
|
| Hospital Charge Code |
41640240
|
|
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
|
|
|
DIAZEPAM 5 MG TAB
|
Facility
|
OP
|
$1.00
|
|
| Hospital Charge Code |
41650240
|
|
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
|
|
|
DIAZEPAM RECTAL 10 MG
|
Facility
|
OP
|
$325.00
|
|
| Hospital Charge Code |
41644299
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$113.75 |
| Max. Negotiated Rate |
$260.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$178.75
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$162.50
|
| Rate for Payer: Aetna Government |
$162.50
|
| Rate for Payer: Brighton Health Commercial |
$243.75
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$260.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$221.00
|
| Rate for Payer: Group Health Inc Commercial |
$162.50
|
| Rate for Payer: Group Health Inc Medicare |
$113.75
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$162.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$162.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$211.25
|
|
|
DIAZEPAM RECTAL 10 MG
|
Facility
|
OP
|
$325.00
|
|
| Hospital Charge Code |
41654299
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$113.75 |
| Max. Negotiated Rate |
$260.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$178.75
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$162.50
|
| Rate for Payer: Aetna Government |
$162.50
|
| Rate for Payer: Brighton Health Commercial |
$243.75
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$260.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$221.00
|
| Rate for Payer: Group Health Inc Commercial |
$162.50
|
| Rate for Payer: Group Health Inc Medicare |
$113.75
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$162.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$162.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$211.25
|
|
|
DIAZEPAM RECTAL 2.5 MG
|
Facility
|
OP
|
$267.25
|
|
| Hospital Charge Code |
41652927
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$93.54 |
| Max. Negotiated Rate |
$213.80 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$146.99
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$133.62
|
| Rate for Payer: Aetna Government |
$133.62
|
| Rate for Payer: Brighton Health Commercial |
$200.44
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$213.80
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$181.73
|
| Rate for Payer: Group Health Inc Commercial |
$133.62
|
| Rate for Payer: Group Health Inc Medicare |
$93.54
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$133.62
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$133.62
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$173.71
|
|
|
DIAZEPAM RECTAL 2.5 MG
|
Facility
|
OP
|
$267.25
|
|
| Hospital Charge Code |
41642927
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$93.54 |
| Max. Negotiated Rate |
$213.80 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$146.99
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$133.62
|
| Rate for Payer: Aetna Government |
$133.62
|
| Rate for Payer: Brighton Health Commercial |
$200.44
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$213.80
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$181.73
|
| Rate for Payer: Group Health Inc Commercial |
$133.62
|
| Rate for Payer: Group Health Inc Medicare |
$93.54
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$133.62
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$133.62
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$173.71
|
|
|
DIAZOXIDE 50 MG/ML PO SUSP [19713]
|
Facility
|
OP
|
$12.40
|
|
|
Service Code
|
NDC 00254101019
|
| Hospital Charge Code |
00254101019
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.34 |
| Max. Negotiated Rate |
$9.92 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$6.82
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$6.20
|
| Rate for Payer: Aetna Government |
$6.20
|
| Rate for Payer: Brighton Health Commercial |
$9.30
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$9.92
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$8.43
|
| Rate for Payer: Group Health Inc Commercial |
$6.20
|
| Rate for Payer: Group Health Inc Medicare |
$4.34
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$6.20
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$6.20
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$8.06
|
|
|
DIAZOXIDE 50 MG/ML SUSP 30 ML
|
Facility
|
OP
|
$2.10
|
|
| Hospital Charge Code |
41643858
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.74 |
| Max. Negotiated Rate |
$1.68 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.16
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.05
|
| Rate for Payer: Aetna Government |
$1.05
|
| Rate for Payer: Brighton Health Commercial |
$1.58
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.68
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.43
|
| Rate for Payer: Group Health Inc Commercial |
$1.05
|
| Rate for Payer: Group Health Inc Medicare |
$0.74
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.05
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.05
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.36
|
|
|
DIAZOXIDE 50 MG/ML SUSP 30 ML
|
Facility
|
OP
|
$2.10
|
|
| Hospital Charge Code |
41653858
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.74 |
| Max. Negotiated Rate |
$1.68 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.16
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.05
|
| Rate for Payer: Aetna Government |
$1.05
|
| Rate for Payer: Brighton Health Commercial |
$1.58
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.68
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.43
|
| Rate for Payer: Group Health Inc Commercial |
$1.05
|
| Rate for Payer: Group Health Inc Medicare |
$0.74
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.05
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.05
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.36
|
|
|
DICLOXACILLIN 250 MG CAP
|
Facility
|
OP
|
$1.00
|
|
| Hospital Charge Code |
41653466
|
|
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
|
|
|
DICLOXACILLIN 250 MG CAP
|
Facility
|
OP
|
$1.00
|
|
| Hospital Charge Code |
41643466
|
|
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
|
|
|
DICLOXACILLIN 500 MG CAP
|
Facility
|
OP
|
$1.00
|
|
| Hospital Charge Code |
41653467
|
|
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
|
|
