|
IND IMG HD RAD NECK
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
HCPCS G2190
|
| Hospital Charge Code |
30300318
|
|
Hospital Revenue Code
|
929
|
| Max. Negotiated Rate |
$94.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.01
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.01
|
| Rate for Payer: Aetna Government |
$0.01
|
| Rate for Payer: Brighton Health Commercial |
$0.01
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.01
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.01
|
| Rate for Payer: Group Health Inc Commercial |
$0.01
|
| Rate for Payer: Group Health Inc Medicare |
$0.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.01
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.01
|
| Rate for Payer: United Healthcare Commercial |
$94.00
|
|
|
INDINAVIR 200 MG CAP
|
Facility
|
OP
|
$3.00
|
|
| Hospital Charge Code |
41651659
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.05 |
| Max. Negotiated Rate |
$2.40 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.65
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.50
|
| Rate for Payer: Aetna Government |
$1.50
|
| Rate for Payer: Brighton Health Commercial |
$2.25
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2.40
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2.04
|
| Rate for Payer: Group Health Inc Commercial |
$1.50
|
| Rate for Payer: Group Health Inc Medicare |
$1.05
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.95
|
|
|
INDINAVIR 200 MG CAP
|
Facility
|
OP
|
$3.00
|
|
| Hospital Charge Code |
41641659
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.05 |
| Max. Negotiated Rate |
$2.40 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.65
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.50
|
| Rate for Payer: Aetna Government |
$1.50
|
| Rate for Payer: Brighton Health Commercial |
$2.25
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2.40
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2.04
|
| Rate for Payer: Group Health Inc Commercial |
$1.50
|
| Rate for Payer: Group Health Inc Medicare |
$1.05
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.95
|
|
|
INDINAVIR 400 MG CAP
|
Facility
|
OP
|
$6.00
|
|
| Hospital Charge Code |
41642030
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.10 |
| Max. Negotiated Rate |
$4.80 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$3.30
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3.00
|
| Rate for Payer: Aetna Government |
$3.00
|
| Rate for Payer: Brighton Health Commercial |
$4.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$4.80
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$4.08
|
| Rate for Payer: Group Health Inc Commercial |
$3.00
|
| Rate for Payer: Group Health Inc Medicare |
$2.10
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$3.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$3.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3.90
|
|
|
INDINAVIR 400 MG CAP
|
Facility
|
OP
|
$6.00
|
|
| Hospital Charge Code |
41652030
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.10 |
| Max. Negotiated Rate |
$4.80 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$3.30
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3.00
|
| Rate for Payer: Aetna Government |
$3.00
|
| Rate for Payer: Brighton Health Commercial |
$4.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$4.80
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$4.08
|
| Rate for Payer: Group Health Inc Commercial |
$3.00
|
| Rate for Payer: Group Health Inc Medicare |
$2.10
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$3.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$3.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3.90
|
|
|
INDIUM IN-111 OXINE WBC
|
Facility
|
OP
|
$1,472.50
|
|
|
Service Code
|
HCPCS A9570
|
| Hospital Charge Code |
41646585
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$515.38 |
| Max. Negotiated Rate |
$2,961.14 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$809.88
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2,961.14
|
| Rate for Payer: Aetna Government |
$2,961.14
|
| Rate for Payer: Brighton Health Commercial |
$1,104.38
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,178.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,001.30
|
| Rate for Payer: Group Health Inc Commercial |
$736.25
|
| Rate for Payer: Group Health Inc Medicare |
$515.38
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$736.25
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$736.25
|
|
|
INDIUM IN-111 OXINNE WBC
|
Facility
|
OP
|
$1,472.50
|
|
|
Service Code
|
HCPCS A9570
|
| Hospital Charge Code |
41656585
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$515.38 |
| Max. Negotiated Rate |
$2,961.14 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$809.88
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2,961.14
|
| Rate for Payer: Aetna Government |
$2,961.14
|
| Rate for Payer: Brighton Health Commercial |
$1,104.38
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,178.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,001.30
|
| Rate for Payer: Group Health Inc Commercial |
$736.25
|
| Rate for Payer: Group Health Inc Medicare |
$515.38
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$736.25
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$736.25
|
|
|
INDIUM IN 111 OXYQUINOLINE 1 MCI/ML IV SOLN [98452]
|
Facility
|
IP
|
$4,634.82
|
|
|
Service Code
|
HCPCS A9547
|
| Hospital Charge Code |
17156002101
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,317.41 |
| Max. Negotiated Rate |
$2,317.41 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,317.41
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2,317.41
|
|
|
INDIUM IN 111 OXYQUINOLINE 1 MCI/ML IV SOLN [98452]
|
Facility
|
OP
|
$4,634.82
|
|
|
Service Code
|
HCPCS A9547
|
| Hospital Charge Code |
17156002101
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,480.57 |
| Max. Negotiated Rate |
$4,866.56 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,549.15
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,480.57
|
| Rate for Payer: Aetna Government |
$1,480.57
|
| Rate for Payer: Brighton Health Commercial |
$2,780.89
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2,317.41
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,665.02
|
| Rate for Payer: EmblemHealth Commercial |
$2,317.41
|
| Rate for Payer: Fidelis Medicare Advantage |
$4,866.56
|
| Rate for Payer: Group Health Inc Commercial |
$2,317.41
|
| Rate for Payer: Group Health Inc Medicare |
$1,622.19
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,317.41
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2,317.41
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3,012.63
|
|
|
INDIUM IN-111 PENTETREOTIDE
|
Facility
|
OP
|
$1,695.05
|
|
|
Service Code
|
HCPCS A9572
|
| Hospital Charge Code |
41646586
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$593.27 |
| Max. Negotiated Rate |
$4,699.73 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$932.28
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$4,699.73
|
| Rate for Payer: Aetna Government |
$4,699.73
|
| Rate for Payer: Brighton Health Commercial |
$1,271.29
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,356.04
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,152.63
|
| Rate for Payer: Group Health Inc Commercial |
$847.52
|
| Rate for Payer: Group Health Inc Medicare |
$593.27
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$847.52
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$847.52
|
|
|
INDIUM IN-111 PETETREOTIDE
|
Facility
|
OP
|
$1,695.05
|
|
|
Service Code
|
HCPCS A9572
|
| Hospital Charge Code |
41656586
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$593.27 |
| Max. Negotiated Rate |
$4,699.73 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$932.28
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$4,699.73
|
| Rate for Payer: Aetna Government |
$4,699.73
|
| Rate for Payer: Brighton Health Commercial |
$1,271.29
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,356.04
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,152.63
|
| Rate for Payer: Group Health Inc Commercial |
$847.52
|
| Rate for Payer: Group Health Inc Medicare |
$593.27
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$847.52
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$847.52
|
|
|
INDOCYANINE GREEN 25MG INJ
|
Facility
|
OP
|
$91.45
|
|
| Hospital Charge Code |
41647935
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$32.01 |
| Max. Negotiated Rate |
$73.16 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$50.30
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$45.72
|
| Rate for Payer: Aetna Government |
$45.72
|
| Rate for Payer: Brighton Health Commercial |
$68.59
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$73.16
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$62.19
|
| Rate for Payer: Group Health Inc Commercial |
$45.72
|
| Rate for Payer: Group Health Inc Medicare |
$32.01
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$45.72
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$45.72
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$59.44
|
|
|
INDOCYANINE GREEN 25MG INJ
|
Facility
|
OP
|
$91.45
|
|
| Hospital Charge Code |
41657935
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$32.01 |
| Max. Negotiated Rate |
$73.16 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$50.30
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$45.72
|
| Rate for Payer: Aetna Government |
$45.72
|
| Rate for Payer: Brighton Health Commercial |
$68.59
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$73.16
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$62.19
|
| Rate for Payer: Group Health Inc Commercial |
$45.72
|
| Rate for Payer: Group Health Inc Medicare |
$32.01
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$45.72
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$45.72
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$59.44
|
|
|
INDOCYANINE GREEN 25 MG IV SOLR [10266]
|
Facility
|
IP
|
$169.79
|
|
|
Service Code
|
NDC 70100042402
|
| Hospital Charge Code |
70100042402
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$84.90 |
| Max. Negotiated Rate |
$84.90 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$84.90
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$84.90
|
|
|
INDOCYANINE GREEN 25 MG IV SOLR [10266]
|
Facility
|
OP
|
$169.79
|
|
|
Service Code
|
NDC 70100042402
|
| Hospital Charge Code |
70100042402
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$59.43 |
| Max. Negotiated Rate |
$178.28 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$93.39
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$84.90
|
| Rate for Payer: Aetna Government |
$84.90
|
| Rate for Payer: Brighton Health Commercial |
$101.88
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$84.90
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$97.63
|
| Rate for Payer: EmblemHealth Commercial |
$84.90
|
| Rate for Payer: Fidelis Medicare Advantage |
$178.28
|
| Rate for Payer: Group Health Inc Commercial |
$84.90
|
| Rate for Payer: Group Health Inc Medicare |
$59.43
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$84.90
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$84.90
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$110.36
|
|
|
INDOMETHACIN 0.5 MG/ML INJ
|
Facility
|
OP
|
$730.26
|
|
| Hospital Charge Code |
41654395
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$255.59 |
| Max. Negotiated Rate |
$584.21 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$401.64
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$365.13
|
| Rate for Payer: Aetna Government |
$365.13
|
| Rate for Payer: Brighton Health Commercial |
$547.70
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$584.21
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$496.58
|
| Rate for Payer: Group Health Inc Commercial |
$365.13
|
| Rate for Payer: Group Health Inc Medicare |
$255.59
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$365.13
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$365.13
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$474.67
|
|
|
INDOMETHACIN 0.5 MG/ML INJ
|
Facility
|
OP
|
$730.26
|
|
| Hospital Charge Code |
41644395
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$255.59 |
| Max. Negotiated Rate |
$584.21 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$401.64
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$365.13
|
| Rate for Payer: Aetna Government |
$365.13
|
| Rate for Payer: Brighton Health Commercial |
$547.70
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$584.21
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$496.58
|
| Rate for Payer: Group Health Inc Commercial |
$365.13
|
| Rate for Payer: Group Health Inc Medicare |
$255.59
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$365.13
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$365.13
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$474.67
|
|
|
INDOMETHACIN 25 MG CAP
|
Facility
|
OP
|
$1.00
|
|
| Hospital Charge Code |
41640990
|
|
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
|
|
|
INDOMETHACIN 25 MG CAP
|
Facility
|
OP
|
$1.00
|
|
| Hospital Charge Code |
41650990
|
|
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
|
|
|
INDOMETHACIN 25 MG PO CAPS [3897]
|
Facility
|
OP
|
$0.43
|
|
|
Service Code
|
NDC 50268043015
|
| Hospital Charge Code |
50268043015
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.34 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.24
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.22
|
| Rate for Payer: Aetna Government |
$0.22
|
| Rate for Payer: Brighton Health Commercial |
$0.32
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.34
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.29
|
| Rate for Payer: Group Health Inc Commercial |
$0.22
|
| Rate for Payer: Group Health Inc Medicare |
$0.15
|
| 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 |
$0.28
|
|
|
INDOMETHACIN 25 MG PO CAPS [3897]
|
Facility
|
OP
|
$0.43
|
|
|
Service Code
|
NDC 50268043011
|
| Hospital Charge Code |
50268043011
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.34 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.24
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.22
|
| Rate for Payer: Aetna Government |
$0.22
|
| Rate for Payer: Brighton Health Commercial |
$0.32
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.34
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.29
|
| Rate for Payer: Group Health Inc Commercial |
$0.22
|
| Rate for Payer: Group Health Inc Medicare |
$0.15
|
| 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 |
$0.28
|
|
|
INDOMETHACIN 25 MG PO CAPS [3897]
|
Facility
|
OP
|
$0.40
|
|
|
Service Code
|
NDC 68462040601
|
| Hospital Charge Code |
68462040601
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.22
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.20
|
| Rate for Payer: Aetna Government |
$0.20
|
| Rate for Payer: Brighton Health Commercial |
$0.30
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.32
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.27
|
| Rate for Payer: Group Health Inc Commercial |
$0.20
|
| Rate for Payer: Group Health Inc Medicare |
$0.14
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.20
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.20
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.26
|
|
|
INDOMETHACIN 50 MG CAP
|
Facility
|
OP
|
$0.42
|
|
| Hospital Charge Code |
41651545
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.34 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.23
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.21
|
| Rate for Payer: Aetna Government |
$0.21
|
| Rate for Payer: Brighton Health Commercial |
$0.32
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.34
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.29
|
| Rate for Payer: Group Health Inc Commercial |
$0.21
|
| Rate for Payer: Group Health Inc Medicare |
$0.15
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.21
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.21
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.27
|
|
|
INDOMETHACIN 50 MG CAP
|
Facility
|
OP
|
$0.42
|
|
| Hospital Charge Code |
41641545
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.34 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.23
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.21
|
| Rate for Payer: Aetna Government |
$0.21
|
| Rate for Payer: Brighton Health Commercial |
$0.32
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.34
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.29
|
| Rate for Payer: Group Health Inc Commercial |
$0.21
|
| Rate for Payer: Group Health Inc Medicare |
$0.15
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.21
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.21
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.27
|
|
|
INDOMETHACIN 50 MG PO CAPS [3898]
|
Facility
|
OP
|
$0.66
|
|
|
Service Code
|
NDC 50268043111
|
| Hospital Charge Code |
50268043111
|
|
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
|
|
