|
LACOSAMIDE 150 MG TAB
|
Facility
|
OP
|
$15.36
|
|
| Hospital Charge Code |
41655334
|
|
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
|
|
|
LACOSAMIDE 200MG/100ML NS - 1MG
|
Facility
|
IP
|
$74.00
|
|
|
Service Code
|
HCPCS C9254
|
| Hospital Charge Code |
41647140
|
|
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 200MG/100ML NS - 1MG
|
Facility
|
OP
|
$74.00
|
|
|
Service Code
|
HCPCS C9254
|
| Hospital Charge Code |
41657140
|
|
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 200MG/100ML NS - 1MG
|
Facility
|
OP
|
$74.00
|
|
|
Service Code
|
HCPCS C9254
|
| Hospital Charge Code |
41647140
|
|
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 200MG/100ML NS - 1MG
|
Facility
|
IP
|
$74.00
|
|
|
Service Code
|
HCPCS C9254
|
| Hospital Charge Code |
41657140
|
|
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 200 MG/20 ML INJ
|
Facility
|
OP
|
$70.00
|
|
| Hospital Charge Code |
41645355
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.50 |
| Max. Negotiated Rate |
$56.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$38.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$35.00
|
| Rate for Payer: Aetna Government |
$35.00
|
| Rate for Payer: Brighton Health Commercial |
$52.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$56.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$47.60
|
| Rate for Payer: Group Health Inc Commercial |
$35.00
|
| Rate for Payer: Group Health Inc Medicare |
$24.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$35.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$35.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$45.50
|
|
|
LACOSAMIDE 200 MG/20 ML INJ
|
Facility
|
OP
|
$70.00
|
|
| Hospital Charge Code |
41655355
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.50 |
| Max. Negotiated Rate |
$56.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$38.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$35.00
|
| Rate for Payer: Aetna Government |
$35.00
|
| Rate for Payer: Brighton Health Commercial |
$52.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$56.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$47.60
|
| Rate for Payer: Group Health Inc Commercial |
$35.00
|
| Rate for Payer: Group Health Inc Medicare |
$24.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$35.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$35.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$45.50
|
|
|
LACOSAMIDE 200 MG/20ML IV SOLN [96972]
|
Facility
|
OP
|
$3.93
|
|
|
Service Code
|
NDC 25021079120
|
| Hospital Charge Code |
25021079120
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1.37 |
| Max. Negotiated Rate |
$4.12 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2.16
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.96
|
| Rate for Payer: Aetna Government |
$1.96
|
| Rate for Payer: Brighton Health Commercial |
$2.36
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.96
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2.26
|
| Rate for Payer: EmblemHealth Commercial |
$1.96
|
| Rate for Payer: Fidelis Medicare Advantage |
$4.12
|
| Rate for Payer: Group Health Inc Commercial |
$1.96
|
| Rate for Payer: Group Health Inc Medicare |
$1.37
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.96
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.96
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2.55
|
|
|
LACOSAMIDE 200 MG/20ML IV SOLN [96972]
|
Facility
|
IP
|
$4.71
|
|
|
Service Code
|
NDC 69543045520
|
| Hospital Charge Code |
69543045520
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2.36 |
| Max. Negotiated Rate |
$2.36 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.36
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2.36
|
|
|
LACOSAMIDE 200 MG/20ML IV SOLN [96972]
|
Facility
|
IP
|
$3.93
|
|
|
Service Code
|
NDC 25021079120
|
| Hospital Charge Code |
25021079120
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1.96 |
| Max. Negotiated Rate |
$1.96 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.96
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.96
|
|
|
LACOSAMIDE 200 MG/20ML IV SOLN [96972]
|
Facility
|
IP
|
$5.80
|
|
|
Service Code
|
NDC 00131181067
|
| Hospital Charge Code |
00131181067
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2.90 |
| Max. Negotiated Rate |
$2.90 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.90
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2.90
|
|
|
LACOSAMIDE 200 MG/20ML IV SOLN [96972]
|
Facility
|
OP
|
$5.80
|
|
|
Service Code
|
NDC 00131181067
|
| Hospital Charge Code |
00131181067
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2.03 |
| Max. Negotiated Rate |
$6.09 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$3.19
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.90
|
| Rate for Payer: Aetna Government |
$2.90
|
| Rate for Payer: Brighton Health Commercial |
$3.48
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2.90
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$3.34
|
| Rate for Payer: EmblemHealth Commercial |
$2.90
|
| Rate for Payer: Fidelis Medicare Advantage |
$6.09
|
| Rate for Payer: Group Health Inc Commercial |
$2.90
|
| Rate for Payer: Group Health Inc Medicare |
$2.03
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.90
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2.90
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3.77
|
|
|
LACOSAMIDE 200 MG/20ML IV SOLN [96972]
|
Facility
|
OP
|
$4.71
|
|
|
Service Code
|
NDC 69543045520
|
| Hospital Charge Code |
69543045520
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1.65 |
| Max. Negotiated Rate |
$4.95 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2.59
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.36
|
| Rate for Payer: Aetna Government |
$2.36
|
| Rate for Payer: Brighton Health Commercial |
$2.83
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2.36
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2.71
|
| Rate for Payer: EmblemHealth Commercial |
$2.36
|
| Rate for Payer: Fidelis Medicare Advantage |
$4.95
|
| Rate for Payer: Group Health Inc Commercial |
$2.36
|
| Rate for Payer: Group Health Inc Medicare |
$1.65
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.36
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2.36
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3.06
|
|
|
LACOSAMIDE 200 MG/20ML IV SOLN [96972]
|
Facility
|
IP
|
$3.60
|
|
|
Service Code
|
NDC 72266024201
|
| Hospital Charge Code |
72266024201
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1.80 |
| Max. Negotiated Rate |
$1.80 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.80
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.80
|
|
|
LACOSAMIDE 200 MG/20ML IV SOLN [96972]
|
Facility
|
OP
|
$3.60
|
|
|
Service Code
|
NDC 72266024201
|
| Hospital Charge Code |
72266024201
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1.26 |
| Max. Negotiated Rate |
$3.78 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.98
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.80
|
| Rate for Payer: Aetna Government |
$1.80
|
| Rate for Payer: Brighton Health Commercial |
$2.16
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.80
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2.07
|
| Rate for Payer: EmblemHealth Commercial |
$1.80
|
| Rate for Payer: Fidelis Medicare Advantage |
$3.78
|
| Rate for Payer: Group Health Inc Commercial |
$1.80
|
| Rate for Payer: Group Health Inc Medicare |
$1.26
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.80
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.80
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2.34
|
|
|
LACOSAMIDE 50 MG PO TABS [96968]
|
Facility
|
OP
|
$14.13
|
|
|
Service Code
|
NDC 00131247735
|
| Hospital Charge Code |
00131247735
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.95 |
| Max. Negotiated Rate |
$11.31 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$7.77
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$7.07
|
| Rate for Payer: Aetna Government |
$7.07
|
| Rate for Payer: Brighton Health Commercial |
$10.60
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$11.31
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$9.61
|
| Rate for Payer: Group Health Inc Commercial |
$7.07
|
| Rate for Payer: Group Health Inc Medicare |
$4.95
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$7.07
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$7.07
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$9.19
|
|
|
LACOSAMIDE 50 MG PO TABS [96968]
|
Facility
|
OP
|
$10.75
|
|
|
Service Code
|
NDC 62332017160
|
| Hospital Charge Code |
62332017160
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.76 |
| Max. Negotiated Rate |
$8.60 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$5.91
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$5.38
|
| Rate for Payer: Aetna Government |
$5.38
|
| Rate for Payer: Brighton Health Commercial |
$8.06
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$8.60
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$7.31
|
| Rate for Payer: Group Health Inc Commercial |
$5.38
|
| Rate for Payer: Group Health Inc Medicare |
$3.76
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$5.38
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$5.38
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$6.99
|
|
|
LACOSAMIDE 50 MG PO TABS [96968]
|
Facility
|
OP
|
$11.37
|
|
|
Service Code
|
NDC 67877073360
|
| Hospital Charge Code |
67877073360
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.98 |
| Max. Negotiated Rate |
$9.09 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$6.25
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$5.68
|
| Rate for Payer: Aetna Government |
$5.68
|
| Rate for Payer: Brighton Health Commercial |
$8.52
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$9.09
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$7.73
|
| Rate for Payer: Group Health Inc Commercial |
$5.68
|
| Rate for Payer: Group Health Inc Medicare |
$3.98
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$5.68
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$5.68
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$7.39
|
|
|
LACOSAMIDE 50 MG PO TABS [96968]
|
Facility
|
OP
|
$15.55
|
|
|
Service Code
|
NDC 00131247760
|
| Hospital Charge Code |
00131247760
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.44 |
| Max. Negotiated Rate |
$12.44 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$8.55
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$7.77
|
| Rate for Payer: Aetna Government |
$7.77
|
| Rate for Payer: Brighton Health Commercial |
$11.66
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$12.44
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$10.57
|
| Rate for Payer: Group Health Inc Commercial |
$7.77
|
| Rate for Payer: Group Health Inc Medicare |
$5.44
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$7.77
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$7.77
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$10.11
|
|
|
LACOSAMIDE 50 MG PO TABS [96968]
|
Facility
|
OP
|
$1.48
|
|
|
Service Code
|
NDC 00904724468
|
| Hospital Charge Code |
00904724468
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.52 |
| Max. Negotiated Rate |
$1.18 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.81
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.74
|
| Rate for Payer: Aetna Government |
$0.74
|
| Rate for Payer: Brighton Health Commercial |
$1.11
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.18
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.00
|
| Rate for Payer: Group Health Inc Commercial |
$0.74
|
| Rate for Payer: Group Health Inc Medicare |
$0.52
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.74
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.74
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.96
|
|
|
LACOSAMIDE 50 MG TAB
|
Facility
|
OP
|
$9.27
|
|
| Hospital Charge Code |
41645346
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.24 |
| Max. Negotiated Rate |
$7.42 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$5.10
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$4.64
|
| Rate for Payer: Aetna Government |
$4.64
|
| Rate for Payer: Brighton Health Commercial |
$6.95
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$7.42
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$6.30
|
| Rate for Payer: Group Health Inc Commercial |
$4.64
|
| Rate for Payer: Group Health Inc Medicare |
$3.24
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4.64
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4.64
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$6.03
|
|
|
LACOSAMIDE 50 MG TAB
|
Facility
|
OP
|
$9.27
|
|
| Hospital Charge Code |
41655346
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.24 |
| Max. Negotiated Rate |
$7.42 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$5.10
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$4.64
|
| Rate for Payer: Aetna Government |
$4.64
|
| Rate for Payer: Brighton Health Commercial |
$6.95
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$7.42
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$6.30
|
| Rate for Payer: Group Health Inc Commercial |
$4.64
|
| Rate for Payer: Group Health Inc Medicare |
$3.24
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4.64
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4.64
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$6.03
|
|
|
LAC REPAIR INTERMED 20-30 CM
|
Facility
|
OP
|
$1,505.35
|
|
|
Service Code
|
HCPCS 12036
|
| Hospital Charge Code |
30107512
|
|
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 |
$752.68
|
| 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
|
|
|
LAC REPAIR INTERMED 20-30 CM
|
Facility
|
IP
|
$1,505.35
|
|
|
Service Code
|
HCPCS 12036
|
| Hospital Charge Code |
30107512
|
|
Hospital Revenue Code
|
450
|
| Rate for Payer: Cash Price |
$726.29
|
|
|
LACTATED RINGERS - 1000CC
|
Facility
|
OP
|
$8.86
|
|
| Hospital Charge Code |
40193500
|
|
Hospital Revenue Code
|
710
|
| Min. Negotiated Rate |
$3.10 |
| Max. Negotiated Rate |
$7.09 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$4.87
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$4.43
|
| Rate for Payer: Aetna Government |
$4.43
|
| Rate for Payer: Brighton Health Commercial |
$6.64
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$7.09
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$6.02
|
| Rate for Payer: Group Health Inc Commercial |
$4.43
|
| Rate for Payer: Group Health Inc Medicare |
$3.10
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4.43
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4.43
|
|
