|
DICLOXACILLIN 500 MG CAP
|
Facility
|
OP
|
$1.00
|
|
| Hospital Charge Code |
41643467
|
|
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 SODIUM 250 MG PO CAPS [2414]
|
Facility
|
OP
|
$1.50
|
|
|
Service Code
|
NDC 00093312301
|
| Hospital Charge Code |
00093312301
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.53 |
| Max. Negotiated Rate |
$1.20 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.83
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.75
|
| Rate for Payer: Aetna Government |
$0.75
|
| Rate for Payer: Brighton Health Commercial |
$1.13
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.20
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.02
|
| Rate for Payer: Group Health Inc Commercial |
$0.75
|
| Rate for Payer: Group Health Inc Medicare |
$0.53
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.75
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.75
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.98
|
|
|
DICYCLOMINE 10 MG CAP
|
Facility
|
OP
|
$0.18
|
|
| Hospital Charge Code |
41654051
|
|
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 |
$0.14
|
| 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
|
|
|
DICYCLOMINE 10 MG CAP
|
Facility
|
OP
|
$0.18
|
|
| Hospital Charge Code |
41644051
|
|
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 |
$0.14
|
| 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
|
|
|
DICYCLOMINE 10 MG/ML INJ
|
Facility
|
OP
|
$65.04
|
|
|
Service Code
|
HCPCS J0500
|
| Hospital Charge Code |
41643411
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.76 |
| Max. Negotiated Rate |
$42.28 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$35.77
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$32.99
|
| Rate for Payer: Aetna Government |
$32.99
|
| Rate for Payer: Brighton Health Commercial |
$39.02
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$32.52
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$37.40
|
| Rate for Payer: Group Health Inc Commercial |
$32.52
|
| Rate for Payer: Group Health Inc Medicare |
$22.76
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$32.52
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$32.52
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$26.48
|
| Rate for Payer: SOMOS Essential |
$26.48
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$42.28
|
|
|
DICYCLOMINE 10 MG/ML INJ
|
Facility
|
IP
|
$65.04
|
|
|
Service Code
|
HCPCS J0500
|
| Hospital Charge Code |
41653411
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$32.52 |
| Max. Negotiated Rate |
$32.52 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$32.52
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$32.52
|
|
|
DICYCLOMINE 10 MG/ML INJ
|
Facility
|
IP
|
$65.04
|
|
|
Service Code
|
HCPCS J0500
|
| Hospital Charge Code |
41643411
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$32.52 |
| Max. Negotiated Rate |
$32.52 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$32.52
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$32.52
|
|
|
DICYCLOMINE 10 MG/ML INJ
|
Facility
|
OP
|
$65.04
|
|
|
Service Code
|
HCPCS J0500
|
| Hospital Charge Code |
41653411
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.76 |
| Max. Negotiated Rate |
$42.28 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$35.77
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$32.99
|
| Rate for Payer: Aetna Government |
$32.99
|
| Rate for Payer: Brighton Health Commercial |
$39.02
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$32.52
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$37.40
|
| Rate for Payer: Group Health Inc Commercial |
$32.52
|
| Rate for Payer: Group Health Inc Medicare |
$22.76
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$32.52
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$32.52
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$26.48
|
| Rate for Payer: SOMOS Essential |
$26.48
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$42.28
|
|
|
DICYCLOMINE 20 MG TAB
|
Facility
|
OP
|
$0.28
|
|
| Hospital Charge Code |
41653485
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.15
|
| 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 |
$0.22
|
| 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 |
$0.18
|
|
|
DICYCLOMINE 20 MG TAB
|
Facility
|
OP
|
$0.28
|
|
| Hospital Charge Code |
41643485
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.15
|
| 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 |
$0.22
|
| 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 |
$0.18
|
|
|
DICYCLOMINE HCL 10 MG/ML IM SOLN [2417]
|
Facility
|
OP
|
$23.40
|
|
|
Service Code
|
HCPCS J0500
|
| Hospital Charge Code |
63323084202
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.19 |
| Max. Negotiated Rate |
$32.99 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$12.87
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$32.99
|
| Rate for Payer: Aetna Government |
$32.99
|
| Rate for Payer: Brighton Health Commercial |
$17.55
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$18.72
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$15.91
|
| Rate for Payer: Group Health Inc Commercial |
$11.70
|
| Rate for Payer: Group Health Inc Medicare |
$8.19
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$11.70
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$11.70
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$24.98
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$26.48
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$26.48
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$26.48
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$15.21
|
|
|
DICYCLOMINE HCL 10 MG/ML IM SOLN [2417]
|
Facility
|
OP
|
$23.40
|
|
|
Service Code
|
HCPCS J0500
|
| Hospital Charge Code |
63323084221
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.19 |
| Max. Negotiated Rate |
$32.99 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$12.87
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$32.99
|
| Rate for Payer: Aetna Government |
$32.99
|
| Rate for Payer: Brighton Health Commercial |
$17.55
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$18.72
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$15.91
|
| Rate for Payer: Group Health Inc Commercial |
$11.70
|
| Rate for Payer: Group Health Inc Medicare |
$8.19
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$11.70
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$11.70
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$24.98
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$26.48
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$26.48
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$26.48
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$15.21
|
|
|
DICYCLOMINE HCL 10 MG/ML IM SOLN [2417]
|
Facility
|
OP
|
$50.44
|
|
|
Service Code
|
HCPCS J0500
|
| Hospital Charge Code |
58914008052
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.65 |
| Max. Negotiated Rate |
$40.35 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$27.74
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$32.99
|
| Rate for Payer: Aetna Government |
$32.99
|
| Rate for Payer: Brighton Health Commercial |
$37.83
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$40.35
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$34.30
|
| Rate for Payer: Group Health Inc Commercial |
$25.22
|
| Rate for Payer: Group Health Inc Medicare |
$17.65
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$25.22
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$25.22
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$24.98
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$26.48
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$26.48
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$26.48
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$32.78
|
|
|
DICYCLOMINE HCL 10 MG PO CAPS [2418]
|
Facility
|
OP
|
$0.66
|
|
|
Service Code
|
NDC 60687036901
|
| Hospital Charge Code |
60687036901
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.53 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.36
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.33
|
| Rate for Payer: Aetna Government |
$0.33
|
| Rate for Payer: Brighton Health Commercial |
$0.49
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.53
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.45
|
| Rate for Payer: Group Health Inc Commercial |
$0.33
|
| Rate for Payer: Group Health Inc Medicare |
$0.23
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.33
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.33
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.43
|
|
|
DICYCLOMINE HCL 10 MG PO CAPS [2418]
|
Facility
|
OP
|
$0.66
|
|
|
Service Code
|
NDC 60687036911
|
| Hospital Charge Code |
60687036911
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.53 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.36
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.33
|
| Rate for Payer: Aetna Government |
$0.33
|
| Rate for Payer: Brighton Health Commercial |
$0.49
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.53
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.45
|
| Rate for Payer: Group Health Inc Commercial |
$0.33
|
| Rate for Payer: Group Health Inc Medicare |
$0.23
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.33
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.33
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.43
|
|
|
DICYCLOMINE HCL 10 MG PO CAPS [2418]
|
Facility
|
OP
|
$0.45
|
|
|
Service Code
|
NDC 00527058601
|
| Hospital Charge Code |
00527058601
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.36 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.25
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.22
|
| Rate for Payer: Aetna Government |
$0.22
|
| Rate for Payer: Brighton Health Commercial |
$0.34
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.36
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.31
|
| Rate for Payer: Group Health Inc Commercial |
$0.22
|
| Rate for Payer: Group Health Inc Medicare |
$0.16
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.22
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.22
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.29
|
|
|
DICYCLOMINE HCL 10 MG PO CAPS [2418]
|
Facility
|
OP
|
$0.68
|
|
|
Service Code
|
NDC 00904698761
|
| Hospital Charge Code |
00904698761
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$0.54 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.37
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.34
|
| Rate for Payer: Aetna Government |
$0.34
|
| Rate for Payer: Brighton Health Commercial |
$0.51
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.54
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.46
|
| Rate for Payer: Group Health Inc Commercial |
$0.34
|
| Rate for Payer: Group Health Inc Medicare |
$0.24
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.34
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.34
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.44
|
|
|
DICYCLOMINE HCL 20 MG PO TABS [2420]
|
Facility
|
OP
|
$0.67
|
|
|
Service Code
|
NDC 00904698861
|
| Hospital Charge Code |
00904698861
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.54 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.37
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.33
|
| Rate for Payer: Aetna Government |
$0.33
|
| Rate for Payer: Brighton Health Commercial |
$0.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.54
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.45
|
| Rate for Payer: Group Health Inc Commercial |
$0.33
|
| Rate for Payer: Group Health Inc Medicare |
$0.23
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.33
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.33
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.43
|
|
|
DICYCLOMINE HCL 20 MG PO TABS [2420]
|
Facility
|
OP
|
$0.78
|
|
|
Service Code
|
NDC 00143122701
|
| Hospital Charge Code |
00143122701
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$0.62 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.43
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.39
|
| Rate for Payer: Aetna Government |
$0.39
|
| Rate for Payer: Brighton Health Commercial |
$0.58
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.62
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.53
|
| Rate for Payer: Group Health Inc Commercial |
$0.39
|
| Rate for Payer: Group Health Inc Medicare |
$0.27
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.39
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.39
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.50
|
|
|
DICYCLOMINE HCL 20 MG PO TABS [2420]
|
Facility
|
OP
|
$0.58
|
|
|
Service Code
|
NDC 00527128201
|
| Hospital Charge Code |
00527128201
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.46 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.32
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.29
|
| Rate for Payer: Aetna Government |
$0.29
|
| Rate for Payer: Brighton Health Commercial |
$0.44
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.46
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.40
|
| Rate for Payer: Group Health Inc Commercial |
$0.29
|
| Rate for Payer: Group Health Inc Medicare |
$0.20
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.29
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.29
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.38
|
|
|
DIDANOSINE 125 MG DR CAP
|
Facility
|
OP
|
$5.40
|
|
| Hospital Charge Code |
41652931
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.89 |
| Max. Negotiated Rate |
$4.32 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2.97
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.70
|
| Rate for Payer: Aetna Government |
$2.70
|
| Rate for Payer: Brighton Health Commercial |
$4.05
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$4.32
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$3.67
|
| Rate for Payer: Group Health Inc Commercial |
$2.70
|
| Rate for Payer: Group Health Inc Medicare |
$1.89
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.70
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2.70
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3.51
|
|
|
DIDANOSINE 125 MG DR CAP
|
Facility
|
OP
|
$5.40
|
|
| Hospital Charge Code |
41642931
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.89 |
| Max. Negotiated Rate |
$4.32 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2.97
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.70
|
| Rate for Payer: Aetna Government |
$2.70
|
| Rate for Payer: Brighton Health Commercial |
$4.05
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$4.32
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$3.67
|
| Rate for Payer: Group Health Inc Commercial |
$2.70
|
| Rate for Payer: Group Health Inc Medicare |
$1.89
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.70
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2.70
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3.51
|
|
|
DIDANOSINE 200 MG DR CAP
|
Facility
|
OP
|
$9.00
|
|
| Hospital Charge Code |
41652811
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.15 |
| Max. Negotiated Rate |
$7.20 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$4.95
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$4.50
|
| Rate for Payer: Aetna Government |
$4.50
|
| Rate for Payer: Brighton Health Commercial |
$6.75
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$7.20
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$6.12
|
| Rate for Payer: Group Health Inc Commercial |
$4.50
|
| Rate for Payer: Group Health Inc Medicare |
$3.15
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$5.85
|
|
|
DIDANOSINE 200 MG DR CAP
|
Facility
|
OP
|
$9.00
|
|
| Hospital Charge Code |
41642811
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.15 |
| Max. Negotiated Rate |
$7.20 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$4.95
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$4.50
|
| Rate for Payer: Aetna Government |
$4.50
|
| Rate for Payer: Brighton Health Commercial |
$6.75
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$7.20
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$6.12
|
| Rate for Payer: Group Health Inc Commercial |
$4.50
|
| Rate for Payer: Group Health Inc Medicare |
$3.15
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$5.85
|
|
|
DIDANOSINE 250 MG DR CAP
|
Facility
|
OP
|
$11.33
|
|
| Hospital Charge Code |
41643803
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.97 |
| Max. Negotiated Rate |
$9.06 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$6.23
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$5.66
|
| Rate for Payer: Aetna Government |
$5.66
|
| Rate for Payer: Brighton Health Commercial |
$8.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$9.06
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$7.70
|
| Rate for Payer: Group Health Inc Commercial |
$5.66
|
| Rate for Payer: Group Health Inc Medicare |
$3.97
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$5.66
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$5.66
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$7.36
|
|
