|
LEVOTHYROXINE SODIUM 500 MCG IV SOLR [113058]
|
Facility
|
OP
|
$633.49
|
|
|
Service Code
|
NDC 63323064810
|
| Hospital Charge Code |
63323064810
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$221.72 |
| Max. Negotiated Rate |
$665.16 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$348.42
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$316.74
|
| Rate for Payer: Aetna Government |
$316.74
|
| Rate for Payer: Brighton Health Commercial |
$380.09
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$316.74
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$364.26
|
| Rate for Payer: EmblemHealth Commercial |
$316.74
|
| Rate for Payer: Fidelis Medicare Advantage |
$665.16
|
| Rate for Payer: Group Health Inc Commercial |
$316.74
|
| Rate for Payer: Group Health Inc Medicare |
$221.72
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$316.74
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$316.74
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$411.77
|
|
|
LEVOTHYROXINE SODIUM 500 MCG IV SOLR [113058]
|
Facility
|
IP
|
$570.78
|
|
|
Service Code
|
NDC 70860045310
|
| Hospital Charge Code |
70860045310
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$285.39 |
| Max. Negotiated Rate |
$285.39 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$285.39
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$285.39
|
|
|
LEVOTHYROXINE SODIUM 500 MCG IV SOLR [113058]
|
Facility
|
OP
|
$570.78
|
|
|
Service Code
|
NDC 70860045310
|
| Hospital Charge Code |
70860045310
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$199.77 |
| Max. Negotiated Rate |
$599.32 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$313.93
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$285.39
|
| Rate for Payer: Aetna Government |
$285.39
|
| Rate for Payer: Brighton Health Commercial |
$342.47
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$285.39
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$328.20
|
| Rate for Payer: EmblemHealth Commercial |
$285.39
|
| Rate for Payer: Fidelis Medicare Advantage |
$599.32
|
| Rate for Payer: Group Health Inc Commercial |
$285.39
|
| Rate for Payer: Group Health Inc Medicare |
$199.77
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$285.39
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$285.39
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$371.01
|
|
|
LEVOTHYROXINE SODIUM 50 MCG PO TABS [4421]
|
Facility
|
OP
|
$1.89
|
|
|
Service Code
|
NDC 00074455211
|
| Hospital Charge Code |
00074455211
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.66 |
| Max. Negotiated Rate |
$1.51 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.04
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.95
|
| Rate for Payer: Aetna Government |
$0.95
|
| Rate for Payer: Brighton Health Commercial |
$1.42
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.51
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.29
|
| Rate for Payer: Group Health Inc Commercial |
$0.95
|
| Rate for Payer: Group Health Inc Medicare |
$0.66
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.95
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.95
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.23
|
|
|
LEVOTHYROXINE SODIUM 50 MCG PO TABS [4421]
|
Facility
|
OP
|
$0.52
|
|
|
Service Code
|
NDC 00527328146
|
| Hospital Charge Code |
00527328146
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.41 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.28
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.26
|
| Rate for Payer: Aetna Government |
$0.26
|
| Rate for Payer: Brighton Health Commercial |
$0.39
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.41
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.35
|
| Rate for Payer: Group Health Inc Commercial |
$0.26
|
| Rate for Payer: Group Health Inc Medicare |
$0.18
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.26
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.26
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.34
|
|
|
LEVOTHYROXINE SODIUM 50 MCG PO TABS [4421]
|
Facility
|
OP
|
$0.50
|
|
|
Service Code
|
NDC 68180096601
|
| Hospital Charge Code |
68180096601
|
|
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
|
|
|
LEVOTHYROXINE SODIUM 50 MCG PO TABS [4421]
|
Facility
|
OP
|
$0.56
|
|
|
Service Code
|
NDC 00904695061
|
| Hospital Charge Code |
00904695061
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.45 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.31
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.28
|
| Rate for Payer: Aetna Government |
$0.28
|
| Rate for Payer: Brighton Health Commercial |
$0.42
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.45
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.38
|
| Rate for Payer: Group Health Inc Commercial |
$0.28
|
| Rate for Payer: Group Health Inc Medicare |
$0.20
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.28
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.28
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.37
|
|
|
LEVOTHYROXINE SODIUM 50 MCG PO TABS [4421]
|
Facility
|
OP
|
$0.19
|
|
|
Service Code
|
NDC 72305005030
|
| Hospital Charge Code |
72305005030
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.10
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.09
|
| Rate for Payer: Aetna Government |
$0.09
|
| Rate for Payer: Brighton Health Commercial |
$0.14
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.15
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.13
|
| Rate for Payer: Group Health Inc Commercial |
$0.09
|
| Rate for Payer: Group Health Inc Medicare |
$0.07
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.09
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.09
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.12
|
|
|
LEVOTHYROXINE SODIUM 50 MCG PO TABS [4421]
|
Facility
|
OP
|
$0.50
|
|
|
Service Code
|
NDC 68180096609
|
| Hospital Charge Code |
68180096609
|
|
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
|
|
|
LEVOTHYROXINE SODIUM 75 MCG PO TABS [4422]
|
Facility
|
OP
|
$1.12
|
|
|
Service Code
|
NDC 60793085201
|
| Hospital Charge Code |
60793085201
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$0.89 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.61
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.56
|
| Rate for Payer: Aetna Government |
$0.56
|
| Rate for Payer: Brighton Health Commercial |
$0.84
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.89
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.76
|
| Rate for Payer: Group Health Inc Commercial |
$0.56
|
| Rate for Payer: Group Health Inc Medicare |
$0.39
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.56
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.56
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.73
|
|
|
LEVOTHYROXINE SODIUM 75 MCG PO TABS [4422]
|
Facility
|
OP
|
$1.89
|
|
|
Service Code
|
NDC 00074518211
|
| Hospital Charge Code |
00074518211
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.66 |
| Max. Negotiated Rate |
$1.51 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.04
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.95
|
| Rate for Payer: Aetna Government |
$0.95
|
| Rate for Payer: Brighton Health Commercial |
$1.42
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.51
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.29
|
| Rate for Payer: Group Health Inc Commercial |
$0.95
|
| Rate for Payer: Group Health Inc Medicare |
$0.66
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.95
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.95
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.23
|
|
|
LEVOTHYROXINE SODIUM 75 MCG PO TABS [4422]
|
Facility
|
OP
|
$0.69
|
|
|
Service Code
|
NDC 00904695161
|
| Hospital Charge Code |
00904695161
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$0.55 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.38
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.34
|
| Rate for Payer: Aetna Government |
$0.34
|
| Rate for Payer: Brighton Health Commercial |
$0.51
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.55
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.47
|
| Rate for Payer: Group Health Inc Commercial |
$0.34
|
| Rate for Payer: Group Health Inc Medicare |
$0.24
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.34
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.34
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.45
|
|
|
LEVOTHYROXINE SODIUM 75 MCG PO TABS [4422]
|
Facility
|
OP
|
$1.89
|
|
|
Service Code
|
NDC 00074518290
|
| Hospital Charge Code |
00074518290
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.66 |
| Max. Negotiated Rate |
$1.51 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.04
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.95
|
| Rate for Payer: Aetna Government |
$0.95
|
| Rate for Payer: Brighton Health Commercial |
$1.42
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.51
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.29
|
| Rate for Payer: Group Health Inc Commercial |
$0.95
|
| Rate for Payer: Group Health Inc Medicare |
$0.66
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.95
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.95
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.23
|
|
|
LEVOTHYROXINE SODIUM 75 MCG PO TABS [4422]
|
Facility
|
OP
|
$0.55
|
|
|
Service Code
|
NDC 00378180577
|
| Hospital Charge Code |
00378180577
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.44 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.30
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.27
|
| Rate for Payer: Aetna Government |
$0.27
|
| Rate for Payer: Brighton Health Commercial |
$0.41
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.44
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.37
|
| Rate for Payer: Group Health Inc Commercial |
$0.27
|
| Rate for Payer: Group Health Inc Medicare |
$0.19
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.27
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.27
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.36
|
|
|
LEVOTHYROXINE SODIUM 75 MCG PO TABS [4422]
|
Facility
|
OP
|
$0.55
|
|
|
Service Code
|
NDC 69238183201
|
| Hospital Charge Code |
69238183201
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.44 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.30
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.27
|
| Rate for Payer: Aetna Government |
$0.27
|
| Rate for Payer: Brighton Health Commercial |
$0.41
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.44
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.37
|
| Rate for Payer: Group Health Inc Commercial |
$0.27
|
| Rate for Payer: Group Health Inc Medicare |
$0.19
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.27
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.27
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.36
|
|
|
LEVOTHYROXINE SODIUM 75 MCG PO TABS [4422]
|
Facility
|
OP
|
$0.20
|
|
|
Service Code
|
NDC 72305007530
|
| Hospital Charge Code |
72305007530
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.11
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.10
|
| Rate for Payer: Aetna Government |
$0.10
|
| Rate for Payer: Brighton Health Commercial |
$0.15
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.16
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.13
|
| Rate for Payer: Group Health Inc Commercial |
$0.10
|
| Rate for Payer: Group Health Inc Medicare |
$0.07
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.10
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.10
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.13
|
|
|
LEVOTHYROXINE SODIUM 88 MCG PO TABS [10403]
|
Facility
|
OP
|
$0.20
|
|
|
Service Code
|
NDC 72305008830
|
| Hospital Charge Code |
72305008830
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.11
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.10
|
| Rate for Payer: Aetna Government |
$0.10
|
| Rate for Payer: Brighton Health Commercial |
$0.15
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.16
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.13
|
| Rate for Payer: Group Health Inc Commercial |
$0.10
|
| Rate for Payer: Group Health Inc Medicare |
$0.07
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.10
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.10
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.13
|
|
|
LEVOTHYROXINE SODIUM 88 MCG PO TABS [10403]
|
Facility
|
OP
|
$0.70
|
|
|
Service Code
|
NDC 00904695261
|
| Hospital Charge Code |
00904695261
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$0.56 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.38
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.35
|
| Rate for Payer: Aetna Government |
$0.35
|
| Rate for Payer: Brighton Health Commercial |
$0.52
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.56
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.48
|
| Rate for Payer: Group Health Inc Commercial |
$0.35
|
| Rate for Payer: Group Health Inc Medicare |
$0.24
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.35
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.35
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.45
|
|
|
LEVOTHYROXINE SODIUM 88 MCG PO TABS [10403]
|
Facility
|
OP
|
$0.56
|
|
|
Service Code
|
NDC 68180096809
|
| Hospital Charge Code |
68180096809
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.45 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.31
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.28
|
| Rate for Payer: Aetna Government |
$0.28
|
| Rate for Payer: Brighton Health Commercial |
$0.42
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.45
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.38
|
| Rate for Payer: Group Health Inc Commercial |
$0.28
|
| Rate for Payer: Group Health Inc Medicare |
$0.20
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.28
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.28
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.36
|
|
|
LEVOTHYROXINE SODIUM 88 MCG PO TABS [10403]
|
Facility
|
OP
|
$0.70
|
|
|
Service Code
|
NDC 60687048601
|
| Hospital Charge Code |
60687048601
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$0.56 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.39
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.35
|
| Rate for Payer: Aetna Government |
$0.35
|
| Rate for Payer: Brighton Health Commercial |
$0.53
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.56
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.48
|
| Rate for Payer: Group Health Inc Commercial |
$0.35
|
| Rate for Payer: Group Health Inc Medicare |
$0.25
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.35
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.35
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.46
|
|
|
LF 4200 LIGA SURE IMPACT
|
Facility
|
OP
|
$1,395.90
|
|
| Hospital Charge Code |
40209570
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$488.56 |
| Max. Negotiated Rate |
$1,116.72 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$767.74
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$697.95
|
| Rate for Payer: Aetna Government |
$697.95
|
| Rate for Payer: Brighton Health Commercial |
$1,046.92
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,116.72
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$949.21
|
| Rate for Payer: Group Health Inc Commercial |
$697.95
|
| Rate for Payer: Group Health Inc Medicare |
$488.56
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$697.95
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$697.95
|
|
|
LG 38-40 B-D MAS KIT WH
|
Facility
|
OP
|
$74.88
|
|
| Hospital Charge Code |
64905845
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$26.21 |
| Max. Negotiated Rate |
$59.90 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$41.18
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$37.44
|
| Rate for Payer: Aetna Government |
$37.44
|
| Rate for Payer: Brighton Health Commercial |
$56.16
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$59.90
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$50.92
|
| Rate for Payer: Group Health Inc Commercial |
$37.44
|
| Rate for Payer: Group Health Inc Medicare |
$26.21
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$37.44
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$37.44
|
|
|
LGV DIFF.AB.PANEL, IFA
|
Facility
|
IP
|
$29.55
|
|
|
Service Code
|
HCPCS 86631
|
| Hospital Charge Code |
40729903
|
|
Hospital Revenue Code
|
302
|
| Rate for Payer: Cash Price |
$11.82
|
|
|
LGV DIFF.AB.PANEL, IFA
|
Facility
|
OP
|
$29.55
|
|
|
Service Code
|
HCPCS 86631
|
| Hospital Charge Code |
40729903
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$8.27 |
| Max. Negotiated Rate |
$22.16 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$16.25
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$11.82
|
| Rate for Payer: Aetna Government |
$11.82
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$8.27
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$8.27
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$8.27
|
| Rate for Payer: Brighton Health Commercial |
$22.16
|
| Rate for Payer: Cash Price |
$11.82
|
| Rate for Payer: Cash Price |
$11.82
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$11.82
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$18.80
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$15.91
|
| Rate for Payer: Elderplan Medicare Advantage |
$11.82
|
| Rate for Payer: EmblemHealth Commercial |
$11.82
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$10.05
|
| Rate for Payer: Fidelis Essential Plan QHP |
$10.52
|
| Rate for Payer: Fidelis Medicare Advantage |
$11.82
|
| Rate for Payer: Fidelis Qualified Health Plan |
$10.52
|
| Rate for Payer: Group Health Inc Commercial |
$11.82
|
| Rate for Payer: Group Health Inc Medicare |
$11.82
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$14.78
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$11.82
|
| Rate for Payer: Healthfirst Medicare Advantage |
$11.82
|
| Rate for Payer: Healthfirst QHP |
$11.82
|
| Rate for Payer: Humana Medicare |
$12.06
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$11.82
|
| Rate for Payer: United Healthcare Commercial |
$14.98
|
| Rate for Payer: United Healthcare Medicare Advantage |
$11.82
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$11.82
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$9.46
|
| Rate for Payer: Wellcare Medicare |
$10.64
|
|
|
LICOX BRAIN PROBE KIT
|
Facility
|
OP
|
$2,278.00
|
|
| Hospital Charge Code |
40205281
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$797.30 |
| Max. Negotiated Rate |
$1,822.40 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,252.90
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,139.00
|
| Rate for Payer: Aetna Government |
$1,139.00
|
| Rate for Payer: Brighton Health Commercial |
$1,708.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,822.40
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,549.04
|
| Rate for Payer: Group Health Inc Commercial |
$1,139.00
|
| Rate for Payer: Group Health Inc Medicare |
$797.30
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,139.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,139.00
|
|
