|
LABIAL VENEER (LAMINATE)-CHAIRSID
|
Facility
|
IP
|
$850.50
|
|
|
Service Code
|
HCPCS D2960
|
| Hospital Charge Code |
42300665
|
|
Hospital Revenue Code
|
361
|
| Rate for Payer: Cash Price |
$1,018.19
|
|
|
LABIAL VENEER (PORCELAIN LAMINATE
|
Facility
|
OP
|
$1,311.19
|
|
|
Service Code
|
HCPCS D2962
|
| Hospital Charge Code |
42300675
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$655.60 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$721.15
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,018.19
|
| Rate for Payer: Aetna Government |
$1,018.19
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$712.73
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$712.73
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$712.73
|
| Rate for Payer: Brighton Health Commercial |
$983.39
|
| Rate for Payer: Cash Price |
$1,018.19
|
| Rate for Payer: Cash Price |
$1,018.19
|
| Rate for Payer: Cash Price |
$1,018.19
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,018.19
|
| 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 |
$1,018.19
|
| Rate for Payer: EmblemHealth Commercial |
$1,018.19
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$865.46
|
| Rate for Payer: Fidelis Essential Plan QHP |
$906.19
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,018.19
|
| Rate for Payer: Fidelis Qualified Health Plan |
$906.19
|
| Rate for Payer: Group Health Inc Commercial |
$1,018.19
|
| Rate for Payer: Group Health Inc Medicare |
$1,018.19
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$655.60
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,018.19
|
| Rate for Payer: Healthfirst Medicare Advantage |
$865.46
|
| Rate for Payer: Healthfirst QHP |
$1,018.19
|
| Rate for Payer: Humana Medicare |
$1,038.55
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,018.19
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,018.19
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,018.19
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$814.55
|
| Rate for Payer: Wellcare Medicare |
$967.28
|
|
|
LABIAL VENEER (PORCELAIN LAMINATE
|
Facility
|
IP
|
$1,311.19
|
|
|
Service Code
|
HCPCS D2962
|
| Hospital Charge Code |
42300675
|
|
Hospital Revenue Code
|
361
|
| Rate for Payer: Cash Price |
$1,018.19
|
|
|
LABIAL VENEER (RESIN LAMINATE)-LA
|
Facility
|
OP
|
$1,169.44
|
|
|
Service Code
|
HCPCS D2961
|
| Hospital Charge Code |
42300670
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$584.72 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$643.19
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,018.19
|
| Rate for Payer: Aetna Government |
$1,018.19
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$712.73
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$712.73
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$712.73
|
| Rate for Payer: Brighton Health Commercial |
$877.08
|
| Rate for Payer: Cash Price |
$1,018.19
|
| Rate for Payer: Cash Price |
$1,018.19
|
| Rate for Payer: Cash Price |
$1,018.19
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,018.19
|
| 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 |
$1,018.19
|
| Rate for Payer: EmblemHealth Commercial |
$1,018.19
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$865.46
|
| Rate for Payer: Fidelis Essential Plan QHP |
$906.19
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,018.19
|
| Rate for Payer: Fidelis Qualified Health Plan |
$906.19
|
| Rate for Payer: Group Health Inc Commercial |
$1,018.19
|
| Rate for Payer: Group Health Inc Medicare |
$1,018.19
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$584.72
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,018.19
|
| Rate for Payer: Healthfirst Medicare Advantage |
$865.46
|
| Rate for Payer: Healthfirst QHP |
$1,018.19
|
| Rate for Payer: Humana Medicare |
$1,038.55
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,018.19
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,018.19
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,018.19
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$814.55
|
| Rate for Payer: Wellcare Medicare |
$967.28
|
|
|
LABIAL VENEER (RESIN LAMINATE)-LA
|
Facility
|
IP
|
$1,169.44
|
|
|
Service Code
|
HCPCS D2961
|
| Hospital Charge Code |
42300670
|
|
Hospital Revenue Code
|
361
|
| Rate for Payer: Cash Price |
$1,018.19
|
|
|
LABRAL TAPE WHITE 1.5MM 36
|
Facility
|
OP
|
$235.00
|
|
| Hospital Charge Code |
64905798
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$82.25 |
| Max. Negotiated Rate |
$188.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$129.25
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$117.50
|
| Rate for Payer: Aetna Government |
$117.50
|
| Rate for Payer: Brighton Health Commercial |
$176.25
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$188.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$159.80
|
| Rate for Payer: Group Health Inc Commercial |
$117.50
|
| Rate for Payer: Group Health Inc Medicare |
$82.25
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$117.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$117.50
|
|
|
LACERATION ORAL CAVITY
|
Facility
|
IP
|
$1,337.85
|
|
|
Service Code
|
HCPCS 40650
|
| Hospital Charge Code |
30107559
|
|
Hospital Revenue Code
|
450
|
| Rate for Payer: Cash Price |
$636.27
|
|
|
LACERATION ORAL CAVITY
|
Facility
|
OP
|
$1,337.85
|
|
|
Service Code
|
HCPCS 40650
|
| Hospital Charge Code |
30107559
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$165.00 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,134.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$636.27
|
| Rate for Payer: Aetna Government |
$636.27
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$445.39
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$445.39
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$445.39
|
| Rate for Payer: Brighton Health Commercial |
$874.00
|
| Rate for Payer: Carelon Behavioral Health CHP/Medicaid |
$636.27
|
| Rate for Payer: Carelon Behavioral Health Medicare Advantage |
$636.27
|
| Rate for Payer: Cash Price |
$636.27
|
| Rate for Payer: Cash Price |
$636.27
|
| Rate for Payer: Cash Price |
$636.27
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$636.27
|
| 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 |
$636.27
|
| Rate for Payer: EmblemHealth Commercial |
$525.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$540.83
|
| Rate for Payer: Fidelis Essential Plan QHP |
$566.28
|
| Rate for Payer: Fidelis Medicare Advantage |
$636.27
|
| Rate for Payer: Fidelis Qualified Health Plan |
$566.28
|
| Rate for Payer: Group Health Inc Commercial |
$525.00
|
| Rate for Payer: Group Health Inc Medicare |
$525.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$668.92
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$636.27
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$165.00
|
| Rate for Payer: Healthfirst Medicare Advantage |
$225.00
|
| Rate for Payer: Healthfirst QHP |
$636.27
|
| Rate for Payer: Humana Medicare |
$649.00
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$636.27
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$636.27
|
| Rate for Payer: United Healthcare Commercial |
$569.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$636.27
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$636.27
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$509.02
|
| Rate for Payer: Wellcare Medicare |
$604.46
|
|
|
LACERATION REPLAIR 20.1 - 30CM
|
Facility
|
OP
|
$919.60
|
|
|
Service Code
|
HCPCS 12046
|
| Hospital Charge Code |
30107558
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$165.00 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,888.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$726.29
|
| Rate for Payer: Aetna Government |
$726.29
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$508.40
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$508.40
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$508.40
|
| Rate for Payer: Brighton Health Commercial |
$874.00
|
| Rate for Payer: Carelon Behavioral Health CHP/Medicaid |
$726.29
|
| Rate for Payer: Carelon Behavioral Health Medicare Advantage |
$726.29
|
| Rate for Payer: Cash Price |
$726.29
|
| Rate for Payer: Cash Price |
$726.29
|
| Rate for Payer: Cash Price |
$726.29
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$726.29
|
| 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 |
$726.29
|
| Rate for Payer: EmblemHealth Commercial |
$525.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$617.35
|
| Rate for Payer: Fidelis Essential Plan QHP |
$646.40
|
| Rate for Payer: Fidelis Medicare Advantage |
$726.29
|
| Rate for Payer: Fidelis Qualified Health Plan |
$646.40
|
| Rate for Payer: Group Health Inc Commercial |
$525.00
|
| Rate for Payer: Group Health Inc Medicare |
$525.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$459.80
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$726.29
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$165.00
|
| Rate for Payer: Healthfirst Medicare Advantage |
$225.00
|
| Rate for Payer: Healthfirst QHP |
$726.29
|
| Rate for Payer: Humana Medicare |
$740.82
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$726.29
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$726.29
|
| Rate for Payer: United Healthcare Commercial |
$569.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$726.29
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$726.29
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$581.03
|
| Rate for Payer: Wellcare Medicare |
$689.98
|
|
|
LACERATION REPLAIR 20.1 - 30CM
|
Facility
|
IP
|
$919.60
|
|
|
Service Code
|
HCPCS 12046
|
| Hospital Charge Code |
30107558
|
|
Hospital Revenue Code
|
450
|
| Rate for Payer: Cash Price |
$726.29
|
|
|
LACOSAMIDE
|
Facility
|
OP
|
$281.25
|
|
|
Service Code
|
HCPCS 80339
|
| Hospital Charge Code |
40609711
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$225.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$154.69
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.01
|
| Rate for Payer: Aetna Government |
$0.01
|
| Rate for Payer: Brighton Health Commercial |
$210.94
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$225.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$191.25
|
| Rate for Payer: Group Health Inc Commercial |
$140.62
|
| Rate for Payer: Group Health Inc Medicare |
$98.44
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$140.62
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$140.62
|
| Rate for Payer: United Healthcare Commercial |
$18.14
|
|
|
LACOSAMIDE 100MG/100ML NS - 1MG
|
Facility
|
OP
|
$74.00
|
|
|
Service Code
|
HCPCS C9254
|
| Hospital Charge Code |
41657141
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$48.10 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$40.70
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.34
|
| Rate for Payer: Aetna Government |
$0.34
|
| Rate for Payer: Brighton Health Commercial |
$44.40
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$37.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$42.55
|
| Rate for Payer: Group Health Inc Commercial |
$37.00
|
| Rate for Payer: Group Health Inc Medicare |
$25.90
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$37.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$37.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$48.10
|
|
|
LACOSAMIDE 100MG/100ML NS - 1MG
|
Facility
|
IP
|
$74.00
|
|
|
Service Code
|
HCPCS C9254
|
| Hospital Charge Code |
41657141
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$37.00 |
| Max. Negotiated Rate |
$37.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$37.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$37.00
|
|
|
LACOSAMIDE 100MG/100ML NS - 1MG
|
Facility
|
IP
|
$74.00
|
|
|
Service Code
|
HCPCS C9254
|
| Hospital Charge Code |
41647141
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$37.00 |
| Max. Negotiated Rate |
$37.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$37.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$37.00
|
|
|
LACOSAMIDE 100MG/100ML NS - 1MG
|
Facility
|
OP
|
$74.00
|
|
|
Service Code
|
HCPCS C9254
|
| Hospital Charge Code |
41647141
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$48.10 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$40.70
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.34
|
| Rate for Payer: Aetna Government |
$0.34
|
| Rate for Payer: Brighton Health Commercial |
$44.40
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$37.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$42.55
|
| Rate for Payer: Group Health Inc Commercial |
$37.00
|
| Rate for Payer: Group Health Inc Medicare |
$25.90
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$37.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$37.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$48.10
|
|
|
LACOSAMIDE 100 MG PO TABS [96969]
|
Facility
|
OP
|
$3.69
|
|
|
Service Code
|
NDC 60687068711
|
| Hospital Charge Code |
60687068711
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.29 |
| Max. Negotiated Rate |
$2.95 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2.03
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.84
|
| Rate for Payer: Aetna Government |
$1.84
|
| Rate for Payer: Brighton Health Commercial |
$2.76
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2.95
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2.51
|
| Rate for Payer: Group Health Inc Commercial |
$1.84
|
| Rate for Payer: Group Health Inc Medicare |
$1.29
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.84
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.84
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2.40
|
|
|
LACOSAMIDE 100 MG PO TABS [96969]
|
Facility
|
OP
|
$2.46
|
|
|
Service Code
|
NDC 00904724568
|
| Hospital Charge Code |
00904724568
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.86 |
| Max. Negotiated Rate |
$1.97 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.35
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.23
|
| Rate for Payer: Aetna Government |
$1.23
|
| Rate for Payer: Brighton Health Commercial |
$1.85
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.97
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.67
|
| Rate for Payer: Group Health Inc Commercial |
$1.23
|
| Rate for Payer: Group Health Inc Medicare |
$0.86
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.23
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.23
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.60
|
|
|
LACOSAMIDE 100 MG PO TABS [96969]
|
Facility
|
OP
|
$24.31
|
|
|
Service Code
|
NDC 00131247860
|
| Hospital Charge Code |
00131247860
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.51 |
| Max. Negotiated Rate |
$19.45 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$13.37
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$12.15
|
| Rate for Payer: Aetna Government |
$12.15
|
| Rate for Payer: Brighton Health Commercial |
$18.23
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$19.45
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$16.53
|
| Rate for Payer: Group Health Inc Commercial |
$12.15
|
| Rate for Payer: Group Health Inc Medicare |
$8.51
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$12.15
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$12.15
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$15.80
|
|
|
LACOSAMIDE 100 MG PO TABS [96969]
|
Facility
|
OP
|
$16.81
|
|
|
Service Code
|
NDC 62332017260
|
| Hospital Charge Code |
62332017260
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.88 |
| Max. Negotiated Rate |
$13.45 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$9.25
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$8.40
|
| Rate for Payer: Aetna Government |
$8.40
|
| Rate for Payer: Brighton Health Commercial |
$12.61
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$13.45
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$11.43
|
| Rate for Payer: Group Health Inc Commercial |
$8.40
|
| Rate for Payer: Group Health Inc Medicare |
$5.88
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$8.40
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$8.40
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$10.93
|
|
|
LACOSAMIDE 100MG TAB
|
Facility
|
OP
|
$9.30
|
|
| Hospital Charge Code |
41646623
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.26 |
| Max. Negotiated Rate |
$7.44 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$5.12
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$4.65
|
| Rate for Payer: Aetna Government |
$4.65
|
| Rate for Payer: Brighton Health Commercial |
$6.98
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$7.44
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$6.32
|
| Rate for Payer: Group Health Inc Commercial |
$4.65
|
| Rate for Payer: Group Health Inc Medicare |
$3.26
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4.65
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4.65
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$6.04
|
|
|
LACOSAMIDE 100MG TAB
|
Facility
|
OP
|
$9.30
|
|
| Hospital Charge Code |
41656623
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.26 |
| Max. Negotiated Rate |
$7.44 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$5.12
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$4.65
|
| Rate for Payer: Aetna Government |
$4.65
|
| Rate for Payer: Brighton Health Commercial |
$6.98
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$7.44
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$6.32
|
| Rate for Payer: Group Health Inc Commercial |
$4.65
|
| Rate for Payer: Group Health Inc Medicare |
$3.26
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4.65
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4.65
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$6.04
|
|
|
LACOSAMIDE 150 MG PO TABS [96970]
|
Facility
|
OP
|
$2.95
|
|
|
Service Code
|
NDC 00904724668
|
| Hospital Charge Code |
00904724668
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.03 |
| Max. Negotiated Rate |
$2.36 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.62
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.48
|
| Rate for Payer: Aetna Government |
$1.48
|
| Rate for Payer: Brighton Health Commercial |
$2.21
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2.36
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2.01
|
| Rate for Payer: Group Health Inc Commercial |
$1.48
|
| Rate for Payer: Group Health Inc Medicare |
$1.03
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.48
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.48
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.92
|
|
|
LACOSAMIDE 150 MG PO TABS [96970]
|
Facility
|
OP
|
$25.74
|
|
|
Service Code
|
NDC 00131247960
|
| Hospital Charge Code |
00131247960
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.01 |
| Max. Negotiated Rate |
$20.59 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$14.16
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$12.87
|
| Rate for Payer: Aetna Government |
$12.87
|
| Rate for Payer: Brighton Health Commercial |
$19.31
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$20.59
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$17.51
|
| Rate for Payer: Group Health Inc Commercial |
$12.87
|
| Rate for Payer: Group Health Inc Medicare |
$9.01
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$12.87
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$12.87
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$16.73
|
|
|
LACOSAMIDE 150 MG PO TABS [96970]
|
Facility
|
OP
|
$17.80
|
|
|
Service Code
|
NDC 62332017360
|
| Hospital Charge Code |
62332017360
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.23 |
| Max. Negotiated Rate |
$14.24 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$9.79
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$8.90
|
| Rate for Payer: Aetna Government |
$8.90
|
| Rate for Payer: Brighton Health Commercial |
$13.35
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$14.24
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$12.11
|
| Rate for Payer: Group Health Inc Commercial |
$8.90
|
| Rate for Payer: Group Health Inc Medicare |
$6.23
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$8.90
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$8.90
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$11.57
|
|
|
LACOSAMIDE 150 MG TAB
|
Facility
|
OP
|
$15.36
|
|
| Hospital Charge Code |
41645334
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.38 |
| Max. Negotiated Rate |
$12.29 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$8.45
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$7.68
|
| Rate for Payer: Aetna Government |
$7.68
|
| Rate for Payer: Brighton Health Commercial |
$11.52
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$12.29
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$10.44
|
| Rate for Payer: Group Health Inc Commercial |
$7.68
|
| Rate for Payer: Group Health Inc Medicare |
$5.38
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$7.68
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$7.68
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$9.98
|
|
