|
Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; lumbar
|
Facility
|
OP
|
$8,438.58
|
|
|
Service Code
|
CPT 63047
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,505.00 |
| Max. Negotiated Rate |
$8,438.58 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$4,065.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$8,273.12
|
| Rate for Payer: Aetna Government |
$8,273.12
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$5,791.18
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$5,791.18
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$5,791.18
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$8,273.12
|
| 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 |
$8,273.12
|
| Rate for Payer: EmblemHealth Commercial |
$1,505.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$7,032.15
|
| Rate for Payer: Fidelis Essential Plan QHP |
$7,363.08
|
| Rate for Payer: Fidelis Medicare Advantage |
$8,273.12
|
| Rate for Payer: Fidelis Qualified Health Plan |
$7,363.08
|
| Rate for Payer: Group Health Inc Commercial |
$8,273.12
|
| Rate for Payer: Group Health Inc Medicare |
$8,273.12
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$8,273.12
|
| Rate for Payer: Healthfirst Medicare Advantage |
$7,032.15
|
| Rate for Payer: Healthfirst QHP |
$8,273.12
|
| Rate for Payer: Humana Medicare |
$8,438.58
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$8,273.12
|
| Rate for Payer: United Healthcare Commercial |
$2,546.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$8,273.12
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$8,273.12
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$6,618.50
|
| Rate for Payer: Wellcare Medicare |
$7,859.46
|
|
|
Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), more than 2 vertebral segments; lumbar
|
Facility
|
OP
|
$8,438.58
|
|
|
Service Code
|
CPT 63017
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,505.00 |
| Max. Negotiated Rate |
$8,438.58 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$4,065.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$8,273.12
|
| Rate for Payer: Aetna Government |
$8,273.12
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$5,791.18
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$5,791.18
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$5,791.18
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$8,273.12
|
| 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 |
$8,273.12
|
| Rate for Payer: EmblemHealth Commercial |
$1,505.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$7,032.15
|
| Rate for Payer: Fidelis Essential Plan QHP |
$7,363.08
|
| Rate for Payer: Fidelis Medicare Advantage |
$8,273.12
|
| Rate for Payer: Fidelis Qualified Health Plan |
$7,363.08
|
| Rate for Payer: Group Health Inc Commercial |
$8,273.12
|
| Rate for Payer: Group Health Inc Medicare |
$8,273.12
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$8,273.12
|
| Rate for Payer: Healthfirst Medicare Advantage |
$7,032.15
|
| Rate for Payer: Healthfirst QHP |
$8,273.12
|
| Rate for Payer: Humana Medicare |
$8,438.58
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$8,273.12
|
| Rate for Payer: United Healthcare Commercial |
$2,546.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$8,273.12
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$8,273.12
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$6,618.50
|
| Rate for Payer: Wellcare Medicare |
$7,859.46
|
|
|
LAMIVUDINE 10 MG/ML ELIXIR
|
Facility
|
OP
|
$1.00
|
|
| Hospital Charge Code |
41640295
|
|
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
|
|
|
LAMIVUDINE 10 MG/ML ELIXIR
|
Facility
|
OP
|
$1.00
|
|
| Hospital Charge Code |
41650295
|
|
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
|
|
|
LAMIVUDINE 10 MG/ML PO SOLN [15881]
|
Facility
|
OP
|
$0.50
|
|
|
Service Code
|
NDC 57237027424
|
| Hospital Charge Code |
57237027424
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.40 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.27
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.25
|
| Rate for Payer: Aetna Government |
$0.25
|
| Rate for Payer: Brighton Health Commercial |
$0.37
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.40
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.34
|
| Rate for Payer: Group Health Inc Commercial |
$0.25
|
| Rate for Payer: Group Health Inc Medicare |
$0.17
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.25
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.25
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.32
|
|
|
LAMIVUDINE 10 MG/ML PO SOLN [15881]
|
Facility
|
OP
|
$0.50
|
|
|
Service Code
|
NDC 54838056670
|
| Hospital Charge Code |
54838056670
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.40 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.27
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.25
|
| Rate for Payer: Aetna Government |
$0.25
|
| Rate for Payer: Brighton Health Commercial |
$0.37
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.40
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.34
|
| Rate for Payer: Group Health Inc Commercial |
$0.25
|
| Rate for Payer: Group Health Inc Medicare |
$0.17
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.25
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.25
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.32
|
|
|
LAMIVUDINE 10 MG/ML PO SOLN [15881]
|
Facility
|
OP
|
$1.18
|
|
|
Service Code
|
NDC 65862005524
|
| Hospital Charge Code |
65862005524
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$0.94 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.65
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.59
|
| Rate for Payer: Aetna Government |
$0.59
|
| Rate for Payer: Brighton Health Commercial |
$0.89
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.94
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.80
|
| Rate for Payer: Group Health Inc Commercial |
$0.59
|
| Rate for Payer: Group Health Inc Medicare |
$0.41
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.59
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.59
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.77
|
|
|
LAMIVUDINE 150 MG PO TABS [15880]
|
Facility
|
OP
|
$7.16
|
|
|
Service Code
|
NDC 60505325106
|
| Hospital Charge Code |
60505325106
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.51 |
| Max. Negotiated Rate |
$5.73 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$3.94
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3.58
|
| Rate for Payer: Aetna Government |
$3.58
|
| Rate for Payer: Brighton Health Commercial |
$5.37
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$5.73
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$4.87
|
| Rate for Payer: Group Health Inc Commercial |
$3.58
|
| Rate for Payer: Group Health Inc Medicare |
$2.51
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$3.58
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$3.58
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$4.65
|
|
|
LAMIVUDINE 150 MG PO TABS [15880]
|
Facility
|
OP
|
$7.16
|
|
|
Service Code
|
NDC 68180060207
|
| Hospital Charge Code |
68180060207
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.51 |
| Max. Negotiated Rate |
$5.73 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$3.94
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3.58
|
| Rate for Payer: Aetna Government |
$3.58
|
| Rate for Payer: Brighton Health Commercial |
$5.37
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$5.73
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$4.87
|
| Rate for Payer: Group Health Inc Commercial |
$3.58
|
| Rate for Payer: Group Health Inc Medicare |
$2.51
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$3.58
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$3.58
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$4.65
|
|
|
LAMIVUDINE 150 MG PO TABS [15880]
|
Facility
|
OP
|
$9.24
|
|
|
Service Code
|
NDC 00904658304
|
| Hospital Charge Code |
00904658304
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.23 |
| Max. Negotiated Rate |
$7.39 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$5.08
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$4.62
|
| Rate for Payer: Aetna Government |
$4.62
|
| Rate for Payer: Brighton Health Commercial |
$6.93
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$7.39
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$6.28
|
| Rate for Payer: Group Health Inc Commercial |
$4.62
|
| Rate for Payer: Group Health Inc Medicare |
$3.23
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4.62
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4.62
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$6.00
|
|
|
LAMIVUDINE 150 MG TAB
|
Facility
|
OP
|
$200.00
|
|
| Hospital Charge Code |
41650132
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$70.00 |
| Max. Negotiated Rate |
$160.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$110.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$100.00
|
| Rate for Payer: Aetna Government |
$100.00
|
| Rate for Payer: Brighton Health Commercial |
$150.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$160.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$136.00
|
| Rate for Payer: Group Health Inc Commercial |
$100.00
|
| Rate for Payer: Group Health Inc Medicare |
$70.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$100.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$100.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$130.00
|
|
|
LAMIVUDINE 150 MG TAB
|
Facility
|
OP
|
$200.00
|
|
| Hospital Charge Code |
41640132
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$70.00 |
| Max. Negotiated Rate |
$160.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$110.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$100.00
|
| Rate for Payer: Aetna Government |
$100.00
|
| Rate for Payer: Brighton Health Commercial |
$150.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$160.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$136.00
|
| Rate for Payer: Group Health Inc Commercial |
$100.00
|
| Rate for Payer: Group Health Inc Medicare |
$70.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$100.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$100.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$130.00
|
|
|
LAMIVUDINE/ABACAVIR 300-600MG
|
Facility
|
OP
|
$29.10
|
|
| Hospital Charge Code |
41653746
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.18 |
| Max. Negotiated Rate |
$23.28 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$16.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$14.55
|
| Rate for Payer: Aetna Government |
$14.55
|
| Rate for Payer: Brighton Health Commercial |
$21.82
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$23.28
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$19.79
|
| Rate for Payer: Group Health Inc Commercial |
$14.55
|
| Rate for Payer: Group Health Inc Medicare |
$10.18
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$14.55
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$14.55
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$18.92
|
|
|
LAMIVUDINE/ABACAVIR 300-600MG
|
Facility
|
OP
|
$29.10
|
|
| Hospital Charge Code |
41643746
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.18 |
| Max. Negotiated Rate |
$23.28 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$16.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$14.55
|
| Rate for Payer: Aetna Government |
$14.55
|
| Rate for Payer: Brighton Health Commercial |
$21.82
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$23.28
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$19.79
|
| Rate for Payer: Group Health Inc Commercial |
$14.55
|
| Rate for Payer: Group Health Inc Medicare |
$10.18
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$14.55
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$14.55
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$18.92
|
|
|
LAMIVUDINE-ZIDOVUDINE 150-300 MG PO TABS [21810]
|
Facility
|
OP
|
$15.53
|
|
|
Service Code
|
NDC 31722050660
|
| Hospital Charge Code |
31722050660
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.43 |
| Max. Negotiated Rate |
$12.42 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$8.54
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$7.76
|
| Rate for Payer: Aetna Government |
$7.76
|
| Rate for Payer: Brighton Health Commercial |
$11.65
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$12.42
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$10.56
|
| Rate for Payer: Group Health Inc Commercial |
$7.76
|
| Rate for Payer: Group Health Inc Medicare |
$5.43
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$7.76
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$7.76
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$10.09
|
|
|
LAMOTRIGINE 100 MG PO TABS [13982]
|
Facility
|
OP
|
$0.17
|
|
|
Service Code
|
NDC 00904700861
|
| Hospital Charge Code |
00904700861
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.09
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.08
|
| Rate for Payer: Aetna Government |
$0.08
|
| Rate for Payer: Brighton Health Commercial |
$0.12
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.13
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.11
|
| Rate for Payer: Group Health Inc Commercial |
$0.08
|
| Rate for Payer: Group Health Inc Medicare |
$0.06
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.08
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.08
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.11
|
|
|
LAMOTRIGINE 100 MG PO TABS [13982]
|
Facility
|
OP
|
$0.23
|
|
|
Service Code
|
NDC 68084031901
|
| Hospital Charge Code |
68084031901
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.13
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.12
|
| Rate for Payer: Aetna Government |
$0.12
|
| Rate for Payer: Brighton Health Commercial |
$0.17
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.18
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.16
|
| Rate for Payer: Group Health Inc Commercial |
$0.12
|
| Rate for Payer: Group Health Inc Medicare |
$0.08
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.12
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.12
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.15
|
|
|
LAMOTRIGINE 100 MG PO TABS [13982]
|
Facility
|
OP
|
$4.75
|
|
|
Service Code
|
NDC 65862022801
|
| Hospital Charge Code |
65862022801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.66 |
| Max. Negotiated Rate |
$3.80 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2.61
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.38
|
| Rate for Payer: Aetna Government |
$2.38
|
| Rate for Payer: Brighton Health Commercial |
$3.56
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$3.80
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$3.23
|
| Rate for Payer: Group Health Inc Commercial |
$2.38
|
| Rate for Payer: Group Health Inc Medicare |
$1.66
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.38
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2.38
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3.09
|
|
|
LAMOTRIGINE 100 MG TAB
|
Facility
|
OP
|
$0.25
|
|
| Hospital Charge Code |
41642707
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.14
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.13
|
| Rate for Payer: Aetna Government |
$0.13
|
| Rate for Payer: Brighton Health Commercial |
$0.19
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.20
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.17
|
| Rate for Payer: Group Health Inc Commercial |
$0.13
|
| Rate for Payer: Group Health Inc Medicare |
$0.09
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.13
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.13
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.16
|
|
|
LAMOTRIGINE 100 MG TAB
|
Facility
|
OP
|
$0.25
|
|
| Hospital Charge Code |
41652707
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.14
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.13
|
| Rate for Payer: Aetna Government |
$0.13
|
| Rate for Payer: Brighton Health Commercial |
$0.19
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.20
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.17
|
| Rate for Payer: Group Health Inc Commercial |
$0.13
|
| Rate for Payer: Group Health Inc Medicare |
$0.09
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.13
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.13
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.16
|
|
|
LAMOTRIGINE 200 MG PO TABS [13983]
|
Facility
|
OP
|
$5.67
|
|
|
Service Code
|
NDC 65862023060
|
| Hospital Charge Code |
65862023060
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.98 |
| Max. Negotiated Rate |
$4.54 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$3.12
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.83
|
| Rate for Payer: Aetna Government |
$2.83
|
| Rate for Payer: Brighton Health Commercial |
$4.25
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$4.54
|
| 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
|
|
|
LAMOTRIGINE 200 MG PO TABS [13983]
|
Facility
|
OP
|
$6.14
|
|
|
Service Code
|
NDC 51672413304
|
| Hospital Charge Code |
51672413304
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.15 |
| Max. Negotiated Rate |
$4.91 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$3.37
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3.07
|
| Rate for Payer: Aetna Government |
$3.07
|
| Rate for Payer: Brighton Health Commercial |
$4.60
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$4.91
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$4.17
|
| Rate for Payer: Group Health Inc Commercial |
$3.07
|
| Rate for Payer: Group Health Inc Medicare |
$2.15
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$3.07
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$3.07
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3.99
|
|
|
LAMOTRIGINE 200 MG TAB
|
Facility
|
OP
|
$0.34
|
|
| Hospital Charge Code |
41653576
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.27 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.19
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.17
|
| Rate for Payer: Aetna Government |
$0.17
|
| Rate for Payer: Brighton Health Commercial |
$0.26
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.27
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.23
|
| 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 |
$0.22
|
|
|
LAMOTRIGINE 200 MG TAB
|
Facility
|
OP
|
$0.34
|
|
| Hospital Charge Code |
41643576
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.27 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.19
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.17
|
| Rate for Payer: Aetna Government |
$0.17
|
| Rate for Payer: Brighton Health Commercial |
$0.26
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.27
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.23
|
| 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 |
$0.22
|
|
|
LAMOTRIGINE 25 MG PO TABS [13981]
|
Facility
|
OP
|
$4.50
|
|
|
Service Code
|
NDC 51672413001
|
| Hospital Charge Code |
51672413001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.58 |
| Max. Negotiated Rate |
$3.60 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2.48
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.25
|
| Rate for Payer: Aetna Government |
$2.25
|
| Rate for Payer: Brighton Health Commercial |
$3.38
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$3.60
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$3.06
|
| Rate for Payer: Group Health Inc Commercial |
$2.25
|
| Rate for Payer: Group Health Inc Medicare |
$1.58
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.25
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2.25
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2.93
|
|
