|
IODINE SERUM OR PLASMA
|
Facility
|
IP
|
$60.28
|
|
|
Service Code
|
HCPCS 83789
|
| Hospital Charge Code |
40609721
|
|
Hospital Revenue Code
|
301
|
| Rate for Payer: Cash Price |
$24.11
|
|
|
IODINE SERUM OR PLASMA
|
Facility
|
OP
|
$60.28
|
|
|
Service Code
|
HCPCS 83789
|
| Hospital Charge Code |
40609721
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$16.88 |
| Max. Negotiated Rate |
$45.21 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$33.15
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$24.11
|
| Rate for Payer: Aetna Government |
$24.11
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$16.88
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$16.88
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$16.88
|
| Rate for Payer: Brighton Health Commercial |
$45.21
|
| Rate for Payer: Cash Price |
$24.11
|
| Rate for Payer: Cash Price |
$24.11
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$24.11
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$28.70
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$24.29
|
| Rate for Payer: Elderplan Medicare Advantage |
$24.11
|
| Rate for Payer: EmblemHealth Commercial |
$24.11
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$20.49
|
| Rate for Payer: Fidelis Essential Plan QHP |
$21.46
|
| Rate for Payer: Fidelis Medicare Advantage |
$24.11
|
| Rate for Payer: Fidelis Qualified Health Plan |
$21.46
|
| Rate for Payer: Group Health Inc Commercial |
$24.11
|
| Rate for Payer: Group Health Inc Medicare |
$24.11
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$30.14
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$24.11
|
| Rate for Payer: Healthfirst Medicare Advantage |
$24.11
|
| Rate for Payer: Healthfirst QHP |
$24.11
|
| Rate for Payer: Humana Medicare |
$24.59
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$24.11
|
| Rate for Payer: United Healthcare Commercial |
$22.87
|
| Rate for Payer: United Healthcare Medicare Advantage |
$24.11
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$24.11
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$19.29
|
| Rate for Payer: Wellcare Medicare |
$21.70
|
|
|
IODINE STRONG 5 % PO SOLN [3961]
|
Facility
|
OP
|
$2.76
|
|
|
Service Code
|
NDC 48433023015
|
| Hospital Charge Code |
48433023015
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.97 |
| Max. Negotiated Rate |
$2.21 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.52
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.38
|
| Rate for Payer: Aetna Government |
$1.38
|
| Rate for Payer: Brighton Health Commercial |
$2.07
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2.21
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.88
|
| Rate for Payer: Group Health Inc Commercial |
$1.38
|
| Rate for Payer: Group Health Inc Medicare |
$0.97
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.38
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.38
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.80
|
|
|
IODIXANOL 270 MG/ML IV SOLN [17594]
|
Facility
|
OP
|
$1.14
|
|
|
Service Code
|
HCPCS Q9966
|
| Hospital Charge Code |
00407222217
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$1.20 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.63
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.34
|
| Rate for Payer: Aetna Government |
$0.34
|
| Rate for Payer: Brighton Health Commercial |
$0.69
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.57
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.66
|
| Rate for Payer: EmblemHealth Commercial |
$0.57
|
| Rate for Payer: Fidelis Medicare Advantage |
$1.20
|
| Rate for Payer: Group Health Inc Commercial |
$0.57
|
| Rate for Payer: Group Health Inc Medicare |
$0.40
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.57
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.57
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.74
|
|
|
IODIXANOL 270 MG/ML IV SOLN [17594]
|
Facility
|
IP
|
$1.14
|
|
|
Service Code
|
HCPCS Q9966
|
| Hospital Charge Code |
00407222217
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$0.57 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.57
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.57
|
|
|
IODIXANOL 320 MG/ML INJ 100 ML
|
Facility
|
IP
|
$1.34
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
41653701
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.67 |
| Max. Negotiated Rate |
$0.67 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.67
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.67
|
|
|
IODIXANOL 320 MG/ML INJ 100 ML
|
Facility
|
OP
|
$1.34
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
41643701
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.87 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.74
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.12
|
| Rate for Payer: Aetna Government |
$0.12
|
| Rate for Payer: Brighton Health Commercial |
$0.80
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.67
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.77
|
| Rate for Payer: Group Health Inc Commercial |
$0.67
|
| Rate for Payer: Group Health Inc Medicare |
$0.47
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.67
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.67
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$0.15
|
| Rate for Payer: SOMOS Essential |
$0.15
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.87
|
|
|
IODIXANOL 320 MG/ML INJ 100 ML
|
Facility
|
IP
|
$1.34
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
41643701
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.67 |
| Max. Negotiated Rate |
$0.67 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.67
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.67
|
|
|
IODIXANOL 320 MG/ML INJ 100 ML
|
Facility
|
OP
|
$1.34
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
41653701
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.87 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.74
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.12
|
| Rate for Payer: Aetna Government |
$0.12
|
| Rate for Payer: Brighton Health Commercial |
$0.80
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.67
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.77
|
| Rate for Payer: Group Health Inc Commercial |
$0.67
|
| Rate for Payer: Group Health Inc Medicare |
$0.47
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.67
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.67
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$0.15
|
| Rate for Payer: SOMOS Essential |
$0.15
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.87
|
|
|
IODIXANOL 320 MG/ML INJ 150 ML
|
Facility
|
IP
|
$1.36
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
41653189
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.68 |
| Max. Negotiated Rate |
$0.68 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.68
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.68
|
|
|
IODIXANOL 320 MG/ML INJ 150 ML
|
Facility
|
IP
|
$1.36
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
41643189
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.68 |
| Max. Negotiated Rate |
$0.68 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.68
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.68
|
|
|
IODIXANOL 320 MG/ML INJ 150 ML
|
Facility
|
OP
|
$1.36
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
41653189
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.88 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.75
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.12
|
| Rate for Payer: Aetna Government |
$0.12
|
| Rate for Payer: Brighton Health Commercial |
$0.82
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.68
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.78
|
| Rate for Payer: Group Health Inc Commercial |
$0.68
|
| Rate for Payer: Group Health Inc Medicare |
$0.48
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.68
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.68
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$0.15
|
| Rate for Payer: SOMOS Essential |
$0.15
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.88
|
|
|
IODIXANOL 320 MG/ML INJ 150 ML
|
Facility
|
OP
|
$1.36
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
41643189
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.88 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.75
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.12
|
| Rate for Payer: Aetna Government |
$0.12
|
| Rate for Payer: Brighton Health Commercial |
$0.82
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.68
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.78
|
| Rate for Payer: Group Health Inc Commercial |
$0.68
|
| Rate for Payer: Group Health Inc Medicare |
$0.48
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.68
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.68
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$0.15
|
| Rate for Payer: SOMOS Essential |
$0.15
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.88
|
|
|
IODIXANOL 320 MG/ML INJ 50 ML
|
Facility
|
OP
|
$1.34
|
|
| Hospital Charge Code |
41643879
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.47 |
| Max. Negotiated Rate |
$1.07 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.74
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.67
|
| Rate for Payer: Aetna Government |
$0.67
|
| Rate for Payer: Brighton Health Commercial |
$1.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.07
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.91
|
| Rate for Payer: Group Health Inc Commercial |
$0.67
|
| Rate for Payer: Group Health Inc Medicare |
$0.47
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.67
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.67
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.87
|
|
|
IODIXANOL 320 MG/ML INJ 50 ML
|
Facility
|
OP
|
$1.34
|
|
| Hospital Charge Code |
41653879
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.47 |
| Max. Negotiated Rate |
$1.07 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.74
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.67
|
| Rate for Payer: Aetna Government |
$0.67
|
| Rate for Payer: Brighton Health Commercial |
$1.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.07
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.91
|
| Rate for Payer: Group Health Inc Commercial |
$0.67
|
| Rate for Payer: Group Health Inc Medicare |
$0.47
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.67
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.67
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.87
|
|
|
IODIXANOL 320 MG/ML IV SOLN [17595]
|
Facility
|
OP
|
$1.11
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
00407222323
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$1.17 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.61
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.12
|
| Rate for Payer: Aetna Government |
$0.12
|
| Rate for Payer: Brighton Health Commercial |
$0.67
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.56
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.64
|
| Rate for Payer: EmblemHealth Commercial |
$0.56
|
| Rate for Payer: Fidelis Medicare Advantage |
$1.17
|
| Rate for Payer: Group Health Inc Commercial |
$0.56
|
| Rate for Payer: Group Health Inc Medicare |
$0.39
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.56
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.56
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.72
|
|
|
IODIXANOL 320 MG/ML IV SOLN [17595]
|
Facility
|
OP
|
$1.27
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
00407222317
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$1.33 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.70
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.12
|
| Rate for Payer: Aetna Government |
$0.12
|
| Rate for Payer: Brighton Health Commercial |
$0.76
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.64
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.73
|
| Rate for Payer: EmblemHealth Commercial |
$0.64
|
| Rate for Payer: Fidelis Medicare Advantage |
$1.33
|
| Rate for Payer: Group Health Inc Commercial |
$0.64
|
| Rate for Payer: Group Health Inc Medicare |
$0.44
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.64
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.64
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.83
|
|
|
IODIXANOL 320 MG/ML IV SOLN [17595]
|
Facility
|
IP
|
$1.11
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
00407222323
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$0.56 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.56
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.56
|
|
|
IODIXANOL 320 MG/ML IV SOLN [17595]
|
Facility
|
IP
|
$1.19
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
00407222319
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$0.60 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.60
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.60
|
|
|
IODIXANOL 320 MG/ML IV SOLN [17595]
|
Facility
|
IP
|
$1.27
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
00407222316
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$0.64 |
| Max. Negotiated Rate |
$0.64 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.64
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.64
|
|
|
IODIXANOL 320 MG/ML IV SOLN [17595]
|
Facility
|
OP
|
$1.27
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
00407222316
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$1.34 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.70
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.12
|
| Rate for Payer: Aetna Government |
$0.12
|
| Rate for Payer: Brighton Health Commercial |
$0.76
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.64
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.73
|
| Rate for Payer: EmblemHealth Commercial |
$0.64
|
| Rate for Payer: Fidelis Medicare Advantage |
$1.34
|
| Rate for Payer: Group Health Inc Commercial |
$0.64
|
| Rate for Payer: Group Health Inc Medicare |
$0.45
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.64
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.64
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.83
|
|
|
IODIXANOL 320 MG/ML IV SOLN [17595]
|
Facility
|
OP
|
$1.19
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
00407222319
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$1.25 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.66
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.12
|
| Rate for Payer: Aetna Government |
$0.12
|
| Rate for Payer: Brighton Health Commercial |
$0.72
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.60
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.69
|
| Rate for Payer: EmblemHealth Commercial |
$0.60
|
| Rate for Payer: Fidelis Medicare Advantage |
$1.25
|
| Rate for Payer: Group Health Inc Commercial |
$0.60
|
| Rate for Payer: Group Health Inc Medicare |
$0.42
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.60
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.60
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.78
|
|
|
IODIXANOL 320 MG/ML IV SOLN [17595]
|
Facility
|
IP
|
$1.27
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
00407222317
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$0.64 |
| Max. Negotiated Rate |
$0.64 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.64
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.64
|
|
|
IODOFORM GAUZE 1 SIZE
|
Facility
|
OP
|
$15.24
|
|
| Hospital Charge Code |
40202602
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$5.33 |
| Max. Negotiated Rate |
$12.19 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$8.38
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$7.62
|
| Rate for Payer: Aetna Government |
$7.62
|
| Rate for Payer: Brighton Health Commercial |
$11.43
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$12.19
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$10.36
|
| Rate for Payer: Group Health Inc Commercial |
$7.62
|
| Rate for Payer: Group Health Inc Medicare |
$5.33
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$7.62
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$7.62
|
|
|
IODOFORM GAUZE 2 SIZE
|
Facility
|
OP
|
$3.85
|
|
| Hospital Charge Code |
40202603
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$1.35 |
| Max. Negotiated Rate |
$3.08 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2.12
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.92
|
| Rate for Payer: Aetna Government |
$1.92
|
| Rate for Payer: Brighton Health Commercial |
$2.89
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$3.08
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2.62
|
| Rate for Payer: Group Health Inc Commercial |
$1.92
|
| Rate for Payer: Group Health Inc Medicare |
$1.35
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.92
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.92
|
|
