|
ISOSORBIDE MONONITRATE ER 120 MG PO TB24 [27278]
|
Facility
|
OP
|
$8.80
|
|
|
Service Code
|
NDC 13668010601
|
| Hospital Charge Code |
13668010601
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.08 |
| Max. Negotiated Rate |
$7.04 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$4.84
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$4.40
|
| Rate for Payer: Aetna Government |
$4.40
|
| Rate for Payer: Brighton Health Commercial |
$6.60
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$7.04
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$5.99
|
| Rate for Payer: Group Health Inc Commercial |
$4.40
|
| Rate for Payer: Group Health Inc Medicare |
$3.08
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4.40
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4.40
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$5.72
|
|
|
ISOSORBIDE MONONITRATE ER 120 MG PO TB24 [27278]
|
Facility
|
OP
|
$2.32
|
|
|
Service Code
|
NDC 50268045315
|
| Hospital Charge Code |
50268045315
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.81 |
| Max. Negotiated Rate |
$1.86 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.28
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.16
|
| Rate for Payer: Aetna Government |
$1.16
|
| Rate for Payer: Brighton Health Commercial |
$1.74
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.86
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.58
|
| Rate for Payer: Group Health Inc Commercial |
$1.16
|
| Rate for Payer: Group Health Inc Medicare |
$0.81
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.16
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.16
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.51
|
|
|
ISOSORBIDE MONONITRATE ER 30 MG PO TB24 [24521]
|
Facility
|
OP
|
$1.06
|
|
|
Service Code
|
NDC 23155051905
|
| Hospital Charge Code |
23155051905
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$0.85 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.58
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.53
|
| Rate for Payer: Aetna Government |
$0.53
|
| Rate for Payer: Brighton Health Commercial |
$0.80
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.85
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.72
|
| Rate for Payer: Group Health Inc Commercial |
$0.53
|
| Rate for Payer: Group Health Inc Medicare |
$0.37
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.53
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.53
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.69
|
|
|
ISOSORBIDE MONONITRATE ER 30 MG PO TB24 [24521]
|
Facility
|
OP
|
$1.05
|
|
|
Service Code
|
NDC 62175012841
|
| Hospital Charge Code |
62175012841
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$0.84 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.58
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.53
|
| Rate for Payer: Aetna Government |
$0.53
|
| Rate for Payer: Brighton Health Commercial |
$0.79
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.84
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.71
|
| Rate for Payer: Group Health Inc Commercial |
$0.53
|
| Rate for Payer: Group Health Inc Medicare |
$0.37
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.53
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.53
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.68
|
|
|
ISOSORBIDE MONONITRATE ER 30 MG PO TB24 [24521]
|
Facility
|
OP
|
$1.66
|
|
|
Service Code
|
NDC 00904644961
|
| Hospital Charge Code |
00904644961
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$1.33 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.91
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.83
|
| Rate for Payer: Aetna Government |
$0.83
|
| Rate for Payer: Brighton Health Commercial |
$1.24
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.33
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.13
|
| Rate for Payer: Group Health Inc Commercial |
$0.83
|
| Rate for Payer: Group Health Inc Medicare |
$0.58
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.83
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.83
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.08
|
|
|
ISOSORBIDE MONONITRATE ER 30 MG PO TB24 [24521]
|
Facility
|
OP
|
$3.35
|
|
|
Service Code
|
NDC 13668010401
|
| Hospital Charge Code |
13668010401
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.17 |
| Max. Negotiated Rate |
$2.68 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.84
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.68
|
| Rate for Payer: Aetna Government |
$1.68
|
| Rate for Payer: Brighton Health Commercial |
$2.51
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2.68
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2.28
|
| Rate for Payer: Group Health Inc Commercial |
$1.68
|
| Rate for Payer: Group Health Inc Medicare |
$1.17
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.68
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.68
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2.18
|
|
|
ISOSORBIDE MONONITRATE ER 60 MG PO TB24 [24268]
|
Facility
|
OP
|
$1.43
|
|
|
Service Code
|
NDC 23155017801
|
| Hospital Charge Code |
23155017801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$1.14 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.78
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.71
|
| Rate for Payer: Aetna Government |
$0.71
|
| Rate for Payer: Brighton Health Commercial |
$1.07
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.14
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.97
|
| Rate for Payer: Group Health Inc Commercial |
$0.71
|
| Rate for Payer: Group Health Inc Medicare |
$0.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.71
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.71
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.93
|
|
|
ISOSORBIDE MONONITRATE ER 60 MG PO TB24 [24268]
|
Facility
|
OP
|
$2.03
|
|
|
Service Code
|
NDC 00904645061
|
| Hospital Charge Code |
00904645061
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.71 |
| Max. Negotiated Rate |
$1.62 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.11
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.01
|
| Rate for Payer: Aetna Government |
$1.01
|
| Rate for Payer: Brighton Health Commercial |
$1.52
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.62
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.38
|
| Rate for Payer: Group Health Inc Commercial |
$1.01
|
| Rate for Payer: Group Health Inc Medicare |
$0.71
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.01
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.01
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.32
|
|
|
ISOSORBIDE MONONITRATE ER 60 MG PO TB24 [24268]
|
Facility
|
OP
|
$4.28
|
|
|
Service Code
|
NDC 13668010501
|
| Hospital Charge Code |
13668010501
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$3.42 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2.35
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.14
|
| Rate for Payer: Aetna Government |
$2.14
|
| Rate for Payer: Brighton Health Commercial |
$3.21
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$3.42
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2.91
|
| Rate for Payer: Group Health Inc Commercial |
$2.14
|
| Rate for Payer: Group Health Inc Medicare |
$1.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.14
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2.14
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2.78
|
|
|
ISOSULFAN BLUE 10 MG/ML INJ
|
Facility
|
OP
|
$1,077.57
|
|
| Hospital Charge Code |
41644530
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$377.15 |
| Max. Negotiated Rate |
$862.06 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$592.66
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$538.78
|
| Rate for Payer: Aetna Government |
$538.78
|
| Rate for Payer: Brighton Health Commercial |
$808.18
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$862.06
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$732.75
|
| Rate for Payer: Group Health Inc Commercial |
$538.78
|
| Rate for Payer: Group Health Inc Medicare |
$377.15
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$538.78
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$538.78
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$700.42
|
|
|
ISOSULFAN BLUE 10 MG/ML INJ
|
Facility
|
OP
|
$1,077.57
|
|
| Hospital Charge Code |
41654530
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$377.15 |
| Max. Negotiated Rate |
$862.06 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$592.66
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$538.78
|
| Rate for Payer: Aetna Government |
$538.78
|
| Rate for Payer: Brighton Health Commercial |
$808.18
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$862.06
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$732.75
|
| Rate for Payer: Group Health Inc Commercial |
$538.78
|
| Rate for Payer: Group Health Inc Medicare |
$377.15
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$538.78
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$538.78
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$700.42
|
|
|
ISOVUE 300 150ML
|
Facility
|
OP
|
$656.00
|
|
| Hospital Charge Code |
40201010
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$229.60 |
| Max. Negotiated Rate |
$524.80 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$360.80
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$328.00
|
| Rate for Payer: Aetna Government |
$328.00
|
| Rate for Payer: Brighton Health Commercial |
$492.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$524.80
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$446.08
|
| Rate for Payer: Group Health Inc Commercial |
$328.00
|
| Rate for Payer: Group Health Inc Medicare |
$229.60
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$328.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$328.00
|
|
|
ISOVUE 300 50ML
|
Facility
|
OP
|
$230.00
|
|
| Hospital Charge Code |
40201008
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$80.50 |
| Max. Negotiated Rate |
$184.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$126.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$115.00
|
| Rate for Payer: Aetna Government |
$115.00
|
| Rate for Payer: Brighton Health Commercial |
$172.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$184.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$156.40
|
| Rate for Payer: Group Health Inc Commercial |
$115.00
|
| Rate for Payer: Group Health Inc Medicare |
$80.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$115.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$115.00
|
|
|
ISOVUE 370 100ML - 1 ML
|
Facility
|
OP
|
$35.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
41657168
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$22.75 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$19.25
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.12
|
| Rate for Payer: Aetna Government |
$0.12
|
| Rate for Payer: Brighton Health Commercial |
$21.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$17.50
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$20.12
|
| Rate for Payer: Group Health Inc Commercial |
$17.50
|
| Rate for Payer: Group Health Inc Medicare |
$12.25
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$17.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$17.50
|
| 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 |
$22.75
|
|
|
ISOVUE 370 100ML - 1 ML
|
Facility
|
IP
|
$35.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
41657168
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.50 |
| Max. Negotiated Rate |
$17.50 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$17.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$17.50
|
|
|
ISOVUE 370 100ML - PER ML
|
Facility
|
OP
|
$35.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
41647168
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$22.75 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$19.25
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.12
|
| Rate for Payer: Aetna Government |
$0.12
|
| Rate for Payer: Brighton Health Commercial |
$21.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$17.50
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$20.12
|
| Rate for Payer: Group Health Inc Commercial |
$17.50
|
| Rate for Payer: Group Health Inc Medicare |
$12.25
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$17.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$17.50
|
| 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 |
$22.75
|
|
|
ISOVUE 370 100ML - PER ML
|
Facility
|
IP
|
$35.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
41647168
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.50 |
| Max. Negotiated Rate |
$17.50 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$17.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$17.50
|
|
|
ISTHMUSECTOMY
|
Facility
|
IP
|
$14,640.10
|
|
|
Service Code
|
HCPCS 60210
|
| Hospital Charge Code |
40019966
|
|
Hospital Revenue Code
|
360
|
| Rate for Payer: Cash Price |
$6,672.53
|
|
|
ISTHMUSECTOMY
|
Facility
|
OP
|
$14,640.10
|
|
|
Service Code
|
HCPCS 60210
|
| Hospital Charge Code |
40019966
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,505.00 |
| Max. Negotiated Rate |
$10,980.08 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$3,387.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$6,672.53
|
| Rate for Payer: Aetna Government |
$6,672.53
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$4,670.77
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$4,670.77
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$4,670.77
|
| Rate for Payer: Brighton Health Commercial |
$10,980.08
|
| Rate for Payer: Cash Price |
$6,672.53
|
| Rate for Payer: Cash Price |
$6,672.53
|
| Rate for Payer: Cash Price |
$6,672.53
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$6,672.53
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2,915.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,477.75
|
| Rate for Payer: Elderplan Medicare Advantage |
$6,672.53
|
| Rate for Payer: EmblemHealth Commercial |
$1,505.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$5,671.65
|
| Rate for Payer: Fidelis Essential Plan QHP |
$5,938.55
|
| Rate for Payer: Fidelis Medicare Advantage |
$6,672.53
|
| Rate for Payer: Fidelis Qualified Health Plan |
$5,938.55
|
| Rate for Payer: Group Health Inc Commercial |
$6,672.53
|
| Rate for Payer: Group Health Inc Medicare |
$6,672.53
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$7,320.05
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$6,672.53
|
| Rate for Payer: Healthfirst Medicare Advantage |
$5,671.65
|
| Rate for Payer: Healthfirst QHP |
$6,672.53
|
| Rate for Payer: Humana Medicare |
$6,805.98
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$6,672.53
|
| Rate for Payer: United Healthcare Commercial |
$2,546.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6,672.53
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$6,672.53
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$5,338.02
|
| Rate for Payer: Wellcare Medicare |
$6,338.90
|
|
|
ITRACONAZOLE 100 MG CAP
|
Facility
|
OP
|
$15.00
|
|
| Hospital Charge Code |
41650205
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.25 |
| Max. Negotiated Rate |
$12.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$8.25
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$7.50
|
| Rate for Payer: Aetna Government |
$7.50
|
| Rate for Payer: Brighton Health Commercial |
$11.25
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$12.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$10.20
|
| Rate for Payer: Group Health Inc Commercial |
$7.50
|
| Rate for Payer: Group Health Inc Medicare |
$5.25
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$7.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$7.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$9.75
|
|
|
ITRACONAZOLE 100 MG CAP
|
Facility
|
OP
|
$15.00
|
|
| Hospital Charge Code |
41640205
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.25 |
| Max. Negotiated Rate |
$12.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$8.25
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$7.50
|
| Rate for Payer: Aetna Government |
$7.50
|
| Rate for Payer: Brighton Health Commercial |
$11.25
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$12.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$10.20
|
| Rate for Payer: Group Health Inc Commercial |
$7.50
|
| Rate for Payer: Group Health Inc Medicare |
$5.25
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$7.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$7.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$9.75
|
|
|
ITRACONAZOLE 100 MG PO CAPS [10364]
|
Facility
|
OP
|
$5.66
|
|
|
Service Code
|
NDC 50268045012
|
| Hospital Charge Code |
50268045012
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.98 |
| Max. Negotiated Rate |
$4.53 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$3.11
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.83
|
| Rate for Payer: Aetna Government |
$2.83
|
| Rate for Payer: Brighton Health Commercial |
$4.24
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$4.53
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$3.85
|
| Rate for Payer: Group Health Inc Commercial |
$2.83
|
| Rate for Payer: Group Health Inc Medicare |
$1.98
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.83
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2.83
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3.68
|
|
|
ITRACONAZOLE 100 MG PO CAPS [10364]
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 60687029925
|
| Hospital Charge Code |
60687029925
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.40 |
| Max. Negotiated Rate |
$3.20 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2.20
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.00
|
| Rate for Payer: Aetna Government |
$2.00
|
| Rate for Payer: Brighton Health Commercial |
$3.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$3.20
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2.72
|
| Rate for Payer: Group Health Inc Commercial |
$2.00
|
| Rate for Payer: Group Health Inc Medicare |
$1.40
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2.60
|
|
|
ITRACONAZOLE 10 MG/ML LIQUID
|
Facility
|
OP
|
$0.33
|
|
| Hospital Charge Code |
41652519
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.18
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.17
|
| Rate for Payer: Aetna Government |
$0.17
|
| Rate for Payer: Brighton Health Commercial |
$0.25
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.26
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.22
|
| Rate for Payer: Group Health Inc Commercial |
$0.17
|
| Rate for Payer: Group Health Inc Medicare |
$0.12
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.17
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.17
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.21
|
|
|
ITRACONAZOLE 10 MG/ML LIQUID
|
Facility
|
OP
|
$0.33
|
|
| Hospital Charge Code |
41642519
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.18
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.17
|
| Rate for Payer: Aetna Government |
$0.17
|
| Rate for Payer: Brighton Health Commercial |
$0.25
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.26
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.22
|
| Rate for Payer: Group Health Inc Commercial |
$0.17
|
| Rate for Payer: Group Health Inc Medicare |
$0.12
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.17
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.17
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.21
|
|
