|
DILTIAZEM HCL 25 MG/5ML IV SOLN [97252]
|
Facility
|
IP
|
$0.78
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
70860030105
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$0.39 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.39
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.39
|
|
|
DILTIAZEM HCL 25 MG/5ML IV SOLN [97252]
|
Facility
|
OP
|
$0.78
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
70860030141
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$0.82 |
| 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 |
$0.47
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.39
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.45
|
| Rate for Payer: EmblemHealth Commercial |
$0.39
|
| Rate for Payer: Fidelis Medicare Advantage |
$0.82
|
| 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 |
$0.51
|
|
|
DILTIAZEM HCL 25 MG/5ML IV SOLN [97252]
|
Facility
|
OP
|
$0.91
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
55150042501
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$0.96 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.46
|
| Rate for Payer: Aetna Government |
$0.46
|
| Rate for Payer: Brighton Health Commercial |
$0.55
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.46
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.52
|
| Rate for Payer: EmblemHealth Commercial |
$0.46
|
| Rate for Payer: Fidelis Medicare Advantage |
$0.96
|
| 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 |
$0.59
|
|
|
DILTIAZEM HCL 30 MG PO TABS [2475]
|
Facility
|
OP
|
$0.98
|
|
|
Service Code
|
NDC 00093031805
|
| Hospital Charge Code |
00093031805
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$0.79 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.54
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.49
|
| Rate for Payer: Aetna Government |
$0.49
|
| Rate for Payer: Brighton Health Commercial |
$0.74
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.79
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.67
|
| Rate for Payer: Group Health Inc Commercial |
$0.49
|
| Rate for Payer: Group Health Inc Medicare |
$0.34
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.49
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.49
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.64
|
|
|
DILTIAZEM HCL 30 MG PO TABS [2475]
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 00093031801
|
| Hospital Charge Code |
00093031801
|
|
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
|
|
|
DILTIAZEM HCL 60 MG PO TABS [2476]
|
Facility
|
OP
|
$1.57
|
|
|
Service Code
|
NDC 00093031901
|
| Hospital Charge Code |
00093031901
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$1.25 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.86
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.78
|
| Rate for Payer: Aetna Government |
$0.78
|
| Rate for Payer: Brighton Health Commercial |
$1.18
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.25
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.07
|
| 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 |
$1.02
|
|
|
DILTIAZEM HCL 60 MG PO TABS [2476]
|
Facility
|
OP
|
$1.54
|
|
|
Service Code
|
NDC 00093031905
|
| Hospital Charge Code |
00093031905
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$1.23 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.85
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.77
|
| Rate for Payer: Aetna Government |
$0.77
|
| Rate for Payer: Brighton Health Commercial |
$1.15
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.23
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.05
|
| Rate for Payer: Group Health Inc Commercial |
$0.77
|
| Rate for Payer: Group Health Inc Medicare |
$0.54
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.77
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.77
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.00
|
|
|
DILTIAZEM HCL 90 MG PO TABS [2477]
|
Facility
|
OP
|
$2.14
|
|
|
Service Code
|
NDC 00093032001
|
| Hospital Charge Code |
00093032001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$1.71 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.18
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.07
|
| Rate for Payer: Aetna Government |
$1.07
|
| Rate for Payer: Brighton Health Commercial |
$1.61
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.71
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.46
|
| Rate for Payer: Group Health Inc Commercial |
$1.07
|
| Rate for Payer: Group Health Inc Medicare |
$0.75
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.07
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.07
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.39
|
|
|
DILTIAZEM HCL ER COATED BEADS 120 MG PO CP24 [29270]
|
Facility
|
OP
|
$0.97
|
|
|
Service Code
|
NDC 60687019501
|
| Hospital Charge Code |
60687019501
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$0.77 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.53
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.48
|
| Rate for Payer: Aetna Government |
$0.48
|
| Rate for Payer: Brighton Health Commercial |
$0.73
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.77
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.66
|
| Rate for Payer: Group Health Inc Commercial |
$0.48
|
| Rate for Payer: Group Health Inc Medicare |
$0.34
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.48
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.48
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.63
|
|
|
DILTIAZEM HCL ER COATED BEADS 120 MG PO CP24 [29270]
|
Facility
|
OP
|
$1.22
|
|
|
Service Code
|
NDC 10370082911
|
| Hospital Charge Code |
10370082911
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$0.98 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.67
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.61
|
| Rate for Payer: Aetna Government |
$0.61
|
| Rate for Payer: Brighton Health Commercial |
$0.92
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.98
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.83
|
| Rate for Payer: Group Health Inc Commercial |
$0.61
|
| Rate for Payer: Group Health Inc Medicare |
$0.43
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.61
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.61
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.79
|
|
|
DILTIAZEM HCL ER COATED BEADS 120 MG PO CP24 [29270]
|
Facility
|
OP
|
$0.91
|
|
|
Service Code
|
NDC 24979002607
|
| Hospital Charge Code |
24979002607
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$0.72 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.45
|
| Rate for Payer: Aetna Government |
$0.45
|
| Rate for Payer: Brighton Health Commercial |
$0.68
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.72
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.62
|
| Rate for Payer: Group Health Inc Commercial |
$0.45
|
| Rate for Payer: Group Health Inc Medicare |
$0.32
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.45
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.45
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.59
|
|
|
DILTIAZEM HCL ER COATED BEADS 180 MG PO CP24 [29272]
|
Facility
|
OP
|
$1.51
|
|
|
Service Code
|
NDC 10370083011
|
| Hospital Charge Code |
10370083011
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.53 |
| Max. Negotiated Rate |
$1.21 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.83
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.76
|
| Rate for Payer: Aetna Government |
$0.76
|
| Rate for Payer: Brighton Health Commercial |
$1.13
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.21
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.03
|
| Rate for Payer: Group Health Inc Commercial |
$0.76
|
| Rate for Payer: Group Health Inc Medicare |
$0.53
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.76
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.76
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.98
|
|
|
DILTIAZEM HCL ER COATED BEADS 180 MG PO CP24 [29272]
|
Facility
|
OP
|
$1.16
|
|
|
Service Code
|
NDC 24979002706
|
| Hospital Charge Code |
24979002706
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.40 |
| Max. Negotiated Rate |
$0.92 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.64
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.58
|
| Rate for Payer: Aetna Government |
$0.58
|
| Rate for Payer: Brighton Health Commercial |
$0.87
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.92
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.79
|
| Rate for Payer: Group Health Inc Commercial |
$0.58
|
| Rate for Payer: Group Health Inc Medicare |
$0.40
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.58
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.58
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.75
|
|
|
DILTIAZEM HCL ER COATED BEADS 180 MG PO CP24 [29272]
|
Facility
|
OP
|
$0.97
|
|
|
Service Code
|
NDC 60687020601
|
| Hospital Charge Code |
60687020601
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$0.77 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.53
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.48
|
| Rate for Payer: Aetna Government |
$0.48
|
| Rate for Payer: Brighton Health Commercial |
$0.73
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.77
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.66
|
| Rate for Payer: Group Health Inc Commercial |
$0.48
|
| Rate for Payer: Group Health Inc Medicare |
$0.34
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.48
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.48
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.63
|
|
|
DILTIAZEM HCL ER COATED BEADS 180 MG PO CP24 [29272]
|
Facility
|
OP
|
$0.97
|
|
|
Service Code
|
NDC 60687020611
|
| Hospital Charge Code |
60687020611
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$0.78 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.53
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.49
|
| Rate for Payer: Aetna Government |
$0.49
|
| Rate for Payer: Brighton Health Commercial |
$0.73
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.78
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.66
|
| Rate for Payer: Group Health Inc Commercial |
$0.49
|
| Rate for Payer: Group Health Inc Medicare |
$0.34
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.49
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.49
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.63
|
|
|
DILTIAZEM HCL ER COATED BEADS 240 MG PO CP24 [29274]
|
Facility
|
OP
|
$0.80
|
|
|
Service Code
|
NDC 60687021701
|
| Hospital Charge Code |
60687021701
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$0.64 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.44
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.40
|
| Rate for Payer: Aetna Government |
$0.40
|
| Rate for Payer: Brighton Health Commercial |
$0.60
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.64
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.55
|
| Rate for Payer: Group Health Inc Commercial |
$0.40
|
| Rate for Payer: Group Health Inc Medicare |
$0.28
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.40
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.40
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.52
|
|
|
DILTIAZEM HCL ER COATED BEADS 300 MG PO CP24 [29276]
|
Facility
|
OP
|
$2.12
|
|
|
Service Code
|
NDC 24979002906
|
| Hospital Charge Code |
24979002906
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.74 |
| Max. Negotiated Rate |
$1.70 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.17
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.06
|
| Rate for Payer: Aetna Government |
$1.06
|
| Rate for Payer: Brighton Health Commercial |
$1.59
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.70
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.44
|
| 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 |
$1.38
|
|
|
DILUTE RUSSELL'S VIPER VENOM
|
Facility
|
OP
|
$23.95
|
|
|
Service Code
|
HCPCS 85613
|
| Hospital Charge Code |
40629221
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$6.71 |
| Max. Negotiated Rate |
$17.96 |
| 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: Affinity Essential Plan 1&2 |
$6.71
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$6.71
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$6.71
|
| Rate for Payer: Brighton Health Commercial |
$17.96
|
| 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 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 Medicare Advantage |
$9.58
|
| Rate for Payer: Healthfirst QHP |
$9.58
|
| Rate for Payer: Humana Medicare |
$9.77
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$9.58
|
| Rate for Payer: United Healthcare Commercial |
$12.12
|
| Rate for Payer: United Healthcare 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
|
|
|
DILUTE RUSSELL'S VIPER VENOM
|
Facility
|
IP
|
$23.95
|
|
|
Service Code
|
HCPCS 85613
|
| Hospital Charge Code |
40629221
|
|
Hospital Revenue Code
|
300
|
| Rate for Payer: Cash Price |
$9.58
|
|
|
DIMENHYDRINATE 50 MG PO TABS [2485]
|
Facility
|
OP
|
$0.05
|
|
|
Service Code
|
NDC 00904205159
|
| Hospital Charge Code |
00904205159
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.03
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.03
|
| Rate for Payer: Aetna Government |
$0.03
|
| Rate for Payer: Brighton Health Commercial |
$0.04
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.04
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.04
|
| Rate for Payer: Group Health Inc Commercial |
$0.03
|
| Rate for Payer: Group Health Inc Medicare |
$0.02
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.03
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.03
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.03
|
|
|
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: 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
|
|
|
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: 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
|
|
|
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 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: Affinity Essential Plan 1&2 |
$41.87
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$41.87
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$41.87
|
| Rate for Payer: Brighton Health Commercial |
$32.57
|
| 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: Humana Medicare |
$61.01
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$59.81
|
| Rate for Payer: United Healthcare Commercial |
$37.81
|
| Rate for Payer: United Healthcare 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
|
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: Affinity Essential Plan 1&2 |
$41.87
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$41.87
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$41.87
|
| Rate for Payer: Brighton Health Commercial |
$32.57
|
| 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: Humana Medicare |
$61.01
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$59.81
|
| Rate for Payer: United Healthcare Commercial |
$37.81
|
| Rate for Payer: United Healthcare 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
|
|
