|
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
|
|
|
DIMETHYL SULFOXIDE 50 % IS SOLN [9873]
|
Facility
|
OP
|
$16.68
|
|
|
Service Code
|
HCPCS J1212
|
| Hospital Charge Code |
67457017750
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.34 |
| Max. Negotiated Rate |
$720.97 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$9.17
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$680.82
|
| Rate for Payer: Aetna Government |
$680.82
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$476.57
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$476.57
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$476.57
|
| Rate for Payer: Brighton Health Commercial |
$12.51
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$680.82
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$13.34
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$11.34
|
| Rate for Payer: Elderplan Medicare Advantage |
$680.82
|
| Rate for Payer: EmblemHealth Commercial |
$680.82
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$578.70
|
| Rate for Payer: Fidelis Essential Plan QHP |
$605.93
|
| Rate for Payer: Fidelis Medicare Advantage |
$680.82
|
| Rate for Payer: Fidelis Qualified Health Plan |
$605.93
|
| Rate for Payer: Group Health Inc Commercial |
$680.82
|
| Rate for Payer: Group Health Inc Medicare |
$680.82
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$8.34
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$680.82
|
| Rate for Payer: Healthfirst Medicare Advantage |
$578.70
|
| Rate for Payer: Healthfirst QHP |
$680.82
|
| Rate for Payer: Humana Medicare |
$694.44
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$680.16
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$720.97
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$720.97
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$720.97
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$680.82
|
| Rate for Payer: United Healthcare Medicare Advantage |
$680.82
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$10.84
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$544.66
|
| Rate for Payer: Wellcare Medicare |
$646.78
|
|
|
DIMETHYL SULFOXIDE 50% SOLN
|
Facility
|
IP
|
$170.52
|
|
|
Service Code
|
HCPCS J1212
|
| Hospital Charge Code |
41644799
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$85.26 |
| Max. Negotiated Rate |
$85.26 |
| Rate for Payer: Cash Price |
$680.82
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$85.26
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$85.26
|
|
|
DIMETHYL SULFOXIDE 50% SOLN
|
Facility
|
IP
|
$170.52
|
|
|
Service Code
|
HCPCS J1212
|
| Hospital Charge Code |
41654799
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$85.26 |
| Max. Negotiated Rate |
$85.26 |
| Rate for Payer: Cash Price |
$680.82
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$85.26
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$85.26
|
|
|
DIMETHYL SULFOXIDE 50% SOLN
|
Facility
|
OP
|
$170.52
|
|
|
Service Code
|
HCPCS J1212
|
| Hospital Charge Code |
41644799
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$85.26 |
| Max. Negotiated Rate |
$720.97 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$93.79
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$680.82
|
| Rate for Payer: Aetna Government |
$680.82
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$476.57
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$476.57
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$476.57
|
| Rate for Payer: Brighton Health Commercial |
$102.31
|
| Rate for Payer: Cash Price |
$680.82
|
| Rate for Payer: Cash Price |
$680.82
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$680.82
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$85.26
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$98.05
|
| Rate for Payer: Elderplan Medicare Advantage |
$680.82
|
| Rate for Payer: EmblemHealth Commercial |
$680.82
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$680.82
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$680.82
|
| Rate for Payer: Fidelis Essential Plan QHP |
$714.86
|
| Rate for Payer: Fidelis Medicare Advantage |
$680.82
|
| Rate for Payer: Fidelis Qualified Health Plan |
$714.86
|
| Rate for Payer: Group Health Inc Commercial |
$680.82
|
| Rate for Payer: Group Health Inc Medicare |
$680.82
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$85.26
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$85.26
|
| Rate for Payer: Healthfirst Medicare Advantage |
$578.70
|
| Rate for Payer: Healthfirst QHP |
$680.82
|
| Rate for Payer: Humana Medicare |
$694.44
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$680.82
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$720.97
|
| Rate for Payer: SOMOS Essential |
$720.97
|
| Rate for Payer: United Healthcare Commercial |
$637.71
|
| Rate for Payer: United Healthcare Medicare Advantage |
$680.82
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$110.84
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$544.66
|
| Rate for Payer: Wellcare Medicare |
$646.78
|
|
|
DIMETHYL SULFOXIDE 50% SOLN
|
Facility
|
OP
|
$170.52
|
|
|
Service Code
|
HCPCS J1212
|
| Hospital Charge Code |
41654799
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$85.26 |
| Max. Negotiated Rate |
$720.97 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$93.79
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$680.82
|
| Rate for Payer: Aetna Government |
$680.82
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$476.57
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$476.57
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$476.57
|
| Rate for Payer: Brighton Health Commercial |
$102.31
|
| Rate for Payer: Cash Price |
$680.82
|
| Rate for Payer: Cash Price |
$680.82
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$680.82
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$85.26
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$98.05
|
| Rate for Payer: Elderplan Medicare Advantage |
$680.82
|
| Rate for Payer: EmblemHealth Commercial |
$680.82
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$680.82
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$680.82
|
| Rate for Payer: Fidelis Essential Plan QHP |
$714.86
|
| Rate for Payer: Fidelis Medicare Advantage |
$680.82
|
| Rate for Payer: Fidelis Qualified Health Plan |
$714.86
|
| Rate for Payer: Group Health Inc Commercial |
$680.82
|
| Rate for Payer: Group Health Inc Medicare |
$680.82
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$85.26
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$85.26
|
| Rate for Payer: Healthfirst Medicare Advantage |
$578.70
|
| Rate for Payer: Healthfirst QHP |
$680.82
|
| Rate for Payer: Humana Medicare |
$694.44
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$680.82
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$720.97
|
| Rate for Payer: SOMOS Essential |
$720.97
|
| Rate for Payer: United Healthcare Commercial |
$637.71
|
| Rate for Payer: United Healthcare Medicare Advantage |
$680.82
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$110.84
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$544.66
|
| Rate for Payer: Wellcare Medicare |
$646.78
|
|
|
DINOPROSTONE 10MG VAG INSERT
|
Facility
|
OP
|
$411.82
|
|
| Hospital Charge Code |
41651413
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$144.14 |
| Max. Negotiated Rate |
$329.46 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$226.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$205.91
|
| Rate for Payer: Aetna Government |
$205.91
|
| Rate for Payer: Brighton Health Commercial |
$308.86
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$329.46
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$280.04
|
| Rate for Payer: Group Health Inc Commercial |
$205.91
|
| Rate for Payer: Group Health Inc Medicare |
$144.14
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$205.91
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$205.91
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$267.68
|
|
|
DINOPROSTONE 10MG VAG INSERT
|
Facility
|
OP
|
$411.82
|
|
| Hospital Charge Code |
41641413
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$144.14 |
| Max. Negotiated Rate |
$329.46 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$226.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$205.91
|
| Rate for Payer: Aetna Government |
$205.91
|
| Rate for Payer: Brighton Health Commercial |
$308.86
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$329.46
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$280.04
|
| Rate for Payer: Group Health Inc Commercial |
$205.91
|
| Rate for Payer: Group Health Inc Medicare |
$144.14
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$205.91
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$205.91
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$267.68
|
|
|
DINOPROSTONE 10 MG VA INST [27467]
|
Facility
|
OP
|
$628.78
|
|
|
Service Code
|
NDC 55566280001
|
| Hospital Charge Code |
55566280001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$220.07 |
| Max. Negotiated Rate |
$503.02 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$345.83
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$314.39
|
| Rate for Payer: Aetna Government |
$314.39
|
| Rate for Payer: Brighton Health Commercial |
$471.58
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$503.02
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$427.57
|
| Rate for Payer: Group Health Inc Commercial |
$314.39
|
| Rate for Payer: Group Health Inc Medicare |
$220.07
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$314.39
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$314.39
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$408.71
|
|
|
DINOPROSTONE 20 MG VAG SUPP
|
Facility
|
OP
|
$1,785.00
|
|
| Hospital Charge Code |
41644120
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$624.75 |
| Max. Negotiated Rate |
$1,428.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$981.75
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$892.50
|
| Rate for Payer: Aetna Government |
$892.50
|
| Rate for Payer: Brighton Health Commercial |
$1,338.75
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,428.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,213.80
|
| Rate for Payer: Group Health Inc Commercial |
$892.50
|
| Rate for Payer: Group Health Inc Medicare |
$624.75
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$892.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$892.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,160.25
|
|
|
DINOPROSTONE 20 MG VAG SUPP
|
Facility
|
OP
|
$1,785.00
|
|
| Hospital Charge Code |
41654120
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$624.75 |
| Max. Negotiated Rate |
$1,428.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$981.75
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$892.50
|
| Rate for Payer: Aetna Government |
$892.50
|
| Rate for Payer: Brighton Health Commercial |
$1,338.75
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,428.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,213.80
|
| Rate for Payer: Group Health Inc Commercial |
$892.50
|
| Rate for Payer: Group Health Inc Medicare |
$624.75
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$892.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$892.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,160.25
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ELIXIR UDC
|
Facility
|
OP
|
$2.80
|
|
|
Service Code
|
HCPCS Q0163
|
| Hospital Charge Code |
41653474
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$1.82 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.54
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.01
|
| Rate for Payer: Aetna Government |
$0.01
|
| Rate for Payer: Brighton Health Commercial |
$1.68
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.40
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.61
|
| Rate for Payer: Group Health Inc Commercial |
$1.40
|
| Rate for Payer: Group Health Inc Medicare |
$0.98
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.40
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.40
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.82
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ELIXIR UDC
|
Facility
|
IP
|
$2.80
|
|
|
Service Code
|
HCPCS Q0163
|
| Hospital Charge Code |
41643474
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.40 |
| Max. Negotiated Rate |
$1.40 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.40
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.40
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ELIXIR UDC
|
Facility
|
OP
|
$2.80
|
|
|
Service Code
|
HCPCS Q0163
|
| Hospital Charge Code |
41643474
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$1.82 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.54
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.01
|
| Rate for Payer: Aetna Government |
$0.01
|
| Rate for Payer: Brighton Health Commercial |
$1.68
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.40
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.61
|
| Rate for Payer: Group Health Inc Commercial |
$1.40
|
| Rate for Payer: Group Health Inc Medicare |
$0.98
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.40
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.40
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.82
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ELIXIR UDC
|
Facility
|
IP
|
$2.80
|
|
|
Service Code
|
HCPCS Q0163
|
| Hospital Charge Code |
41653474
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.40 |
| Max. Negotiated Rate |
$1.40 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.40
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.40
|
|
|
DIPHENHYDRAMINE 25 MG/10 ML ELIXIR UDC
|
Facility
|
OP
|
$1.56
|
|
|
Service Code
|
HCPCS Q0163
|
| Hospital Charge Code |
41643475
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$1.01 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.86
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.01
|
| Rate for Payer: Aetna Government |
$0.01
|
| Rate for Payer: Brighton Health Commercial |
$0.94
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.78
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.90
|
| 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 |
$1.01
|
|
|
DIPHENHYDRAMINE 25 MG/10 ML ELIXIR UDC
|
Facility
|
IP
|
$1.56
|
|
|
Service Code
|
HCPCS Q0163
|
| Hospital Charge Code |
41653475
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.78 |
| Max. Negotiated Rate |
$0.78 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.78
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.78
|
|
|
DIPHENHYDRAMINE 25 MG/10 ML ELIXIR UDC
|
Facility
|
OP
|
$1.56
|
|
|
Service Code
|
HCPCS Q0163
|
| Hospital Charge Code |
41653475
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$1.01 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.86
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.01
|
| Rate for Payer: Aetna Government |
$0.01
|
| Rate for Payer: Brighton Health Commercial |
$0.94
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.78
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.90
|
| 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 |
$1.01
|
|
|
DIPHENHYDRAMINE 25 MG/10 ML ELIXIR UDC
|
Facility
|
IP
|
$1.56
|
|
|
Service Code
|
HCPCS Q0163
|
| Hospital Charge Code |
41643475
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.78 |
| Max. Negotiated Rate |
$0.78 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.78
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.78
|
|
|
DIPHENHYDRAMINE 25 MG CAP
|
Facility
|
OP
|
$0.12
|
|
|
Service Code
|
HCPCS Q0163
|
| Hospital Charge Code |
41654666
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.07
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.01
|
| Rate for Payer: Aetna Government |
$0.01
|
| Rate for Payer: Brighton Health Commercial |
$0.07
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.06
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.07
|
| Rate for Payer: Group Health Inc Commercial |
$0.06
|
| Rate for Payer: Group Health Inc Medicare |
$0.04
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.06
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.06
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.08
|
|
|
DIPHENHYDRAMINE 25 MG CAP
|
Facility
|
IP
|
$0.12
|
|
|
Service Code
|
HCPCS Q0163
|
| Hospital Charge Code |
41654666
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.06
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.06
|
|
|
DIPHENHYDRAMINE 25 MG CAP
|
Facility
|
IP
|
$0.12
|
|
|
Service Code
|
HCPCS Q0163
|
| Hospital Charge Code |
41644666
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.06
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.06
|
|
|
DIPHENHYDRAMINE 25 MG CAP
|
Facility
|
OP
|
$0.12
|
|
|
Service Code
|
HCPCS Q0163
|
| Hospital Charge Code |
41644666
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.07
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.01
|
| Rate for Payer: Aetna Government |
$0.01
|
| Rate for Payer: Brighton Health Commercial |
$0.07
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.06
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.07
|
| Rate for Payer: Group Health Inc Commercial |
$0.06
|
| Rate for Payer: Group Health Inc Medicare |
$0.04
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.06
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.06
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.08
|
|
|
DIPHENHYDRAMINE 2.5 MG/ML LIQ
|
Facility
|
OP
|
$8.08
|
|
|
Service Code
|
HCPCS Q0163
|
| Hospital Charge Code |
41642777
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$5.25 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$4.44
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.01
|
| Rate for Payer: Aetna Government |
$0.01
|
| Rate for Payer: Brighton Health Commercial |
$4.85
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$4.04
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$4.65
|
| Rate for Payer: Group Health Inc Commercial |
$4.04
|
| Rate for Payer: Group Health Inc Medicare |
$2.83
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4.04
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4.04
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$5.25
|
|
|
DIPHENHYDRAMINE 2.5 MG/ML LIQ
|
Facility
|
IP
|
$8.08
|
|
|
Service Code
|
HCPCS Q0163
|
| Hospital Charge Code |
41652777
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.04 |
| Max. Negotiated Rate |
$4.04 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4.04
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4.04
|
|
