|
LUMPECTOMY BREAST
|
Facility
|
IP
|
$9,175.75
|
|
|
Service Code
|
HCPCS 19301
|
| Hospital Charge Code |
40014290
|
|
Hospital Revenue Code
|
360
|
| Rate for Payer: Cash Price |
$4,407.98
|
|
|
LUMPECTOMY BREAST
|
Facility
|
OP
|
$9,175.75
|
|
|
Service Code
|
HCPCS 19301
|
| Hospital Charge Code |
40014290
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,468.00 |
| Max. Negotiated Rate |
$6,881.81 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,888.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$4,407.98
|
| Rate for Payer: Aetna Government |
$4,407.98
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$3,085.59
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$3,085.59
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$3,085.59
|
| Rate for Payer: Brighton Health Commercial |
$6,881.81
|
| Rate for Payer: Cash Price |
$4,407.98
|
| Rate for Payer: Cash Price |
$4,407.98
|
| Rate for Payer: Cash Price |
$4,407.98
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$4,407.98
|
| 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 |
$4,407.98
|
| Rate for Payer: EmblemHealth Commercial |
$1,505.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$3,746.78
|
| Rate for Payer: Fidelis Essential Plan QHP |
$3,923.10
|
| Rate for Payer: Fidelis Medicare Advantage |
$4,407.98
|
| Rate for Payer: Fidelis Qualified Health Plan |
$3,923.10
|
| Rate for Payer: Group Health Inc Commercial |
$4,407.98
|
| Rate for Payer: Group Health Inc Medicare |
$4,407.98
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4,587.88
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4,407.98
|
| Rate for Payer: Healthfirst Medicare Advantage |
$3,746.78
|
| Rate for Payer: Healthfirst QHP |
$4,407.98
|
| Rate for Payer: Humana Medicare |
$4,496.14
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$4,407.98
|
| Rate for Payer: United Healthcare Commercial |
$1,468.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$4,407.98
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$4,407.98
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$3,526.38
|
| Rate for Payer: Wellcare Medicare |
$4,187.58
|
|
|
LUNG TRANSPLANT
|
Facility
|
IP
|
$243,941.90
|
|
|
Service Code
|
MSDRG 007
|
| Min. Negotiated Rate |
$82,505.29 |
| Max. Negotiated Rate |
$243,941.90 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$180,868.07
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$177,430.73
|
| Rate for Payer: Aetna Government |
$177,430.73
|
| Rate for Payer: Brighton Health Commercial |
$177,862.80
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$180,979.34
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$211,828.46
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$174,809.94
|
| Rate for Payer: Elderplan Medicare Advantage |
$168,559.19
|
| Rate for Payer: EmblemHealth Commercial |
$105,184.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$177,430.73
|
| Rate for Payer: Group Health Inc Commercial |
$177,430.73
|
| Rate for Payer: Group Health Inc Medicare |
$177,430.73
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$177,430.73
|
| Rate for Payer: Healthfirst Medicare Advantage |
$82,505.29
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$177,430.73
|
| Rate for Payer: United Healthcare Commercial |
$243,941.90
|
| Rate for Payer: United Healthcare Medicare Advantage |
$177,430.73
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$177,430.73
|
| Rate for Payer: Wellcare Medicare |
$168,559.19
|
|
|
LUNG VOLUMES
|
Facility
|
IP
|
$766.58
|
|
|
Service Code
|
HCPCS 94726 TC
|
| Hospital Charge Code |
40402913
|
|
Hospital Revenue Code
|
460
|
| Rate for Payer: Cash Price |
$362.98
|
|
|
LUNG VOLUMES
|
Facility
|
OP
|
$766.58
|
|
|
Service Code
|
HCPCS 94726 TC
|
| Hospital Charge Code |
40402913
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$254.09 |
| Max. Negotiated Rate |
$613.26 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$421.62
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$362.98
|
| Rate for Payer: Aetna Government |
$362.98
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$254.09
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$254.09
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$254.09
|
| Rate for Payer: Brighton Health Commercial |
$574.94
|
| Rate for Payer: Cash Price |
$362.98
|
| Rate for Payer: Cash Price |
$362.98
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$362.98
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$613.26
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$521.27
|
| Rate for Payer: Elderplan Medicare Advantage |
$362.98
|
| Rate for Payer: EmblemHealth Commercial |
$362.98
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$308.53
|
| Rate for Payer: Fidelis Essential Plan QHP |
$323.05
|
| Rate for Payer: Fidelis Medicare Advantage |
$362.98
|
| Rate for Payer: Fidelis Qualified Health Plan |
$323.05
|
| Rate for Payer: Group Health Inc Commercial |
$362.98
|
| Rate for Payer: Group Health Inc Medicare |
$362.98
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$383.29
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$362.98
|
| Rate for Payer: Healthfirst Medicare Advantage |
$308.53
|
| Rate for Payer: Healthfirst QHP |
$362.98
|
| Rate for Payer: Humana Medicare |
$370.24
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$362.98
|
| Rate for Payer: United Healthcare Commercial |
$383.29
|
| Rate for Payer: United Healthcare Medicare Advantage |
$362.98
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$362.98
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$290.38
|
| Rate for Payer: Wellcare Medicare |
$344.83
|
|
|
LUPUS A-C
|
Facility
|
IP
|
$29.63
|
|
|
Service Code
|
HCPCS 85300
|
| Hospital Charge Code |
40617732
|
|
Hospital Revenue Code
|
305
|
| Rate for Payer: Cash Price |
$11.85
|
|
|
LUPUS A-C
|
Facility
|
OP
|
$29.63
|
|
|
Service Code
|
HCPCS 85300
|
| Hospital Charge Code |
40617732
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$8.30 |
| Max. Negotiated Rate |
$22.22 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$16.30
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$11.85
|
| Rate for Payer: Aetna Government |
$11.85
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$8.30
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$8.30
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$8.30
|
| Rate for Payer: Brighton Health Commercial |
$22.22
|
| Rate for Payer: Cash Price |
$11.85
|
| Rate for Payer: Cash Price |
$11.85
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$11.85
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$18.84
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$15.94
|
| Rate for Payer: Elderplan Medicare Advantage |
$11.85
|
| Rate for Payer: EmblemHealth Commercial |
$11.85
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$10.07
|
| Rate for Payer: Fidelis Essential Plan QHP |
$10.55
|
| Rate for Payer: Fidelis Medicare Advantage |
$11.85
|
| Rate for Payer: Fidelis Qualified Health Plan |
$10.55
|
| Rate for Payer: Group Health Inc Commercial |
$11.85
|
| Rate for Payer: Group Health Inc Medicare |
$11.85
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$14.82
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$11.85
|
| Rate for Payer: Healthfirst Medicare Advantage |
$11.85
|
| Rate for Payer: Healthfirst QHP |
$11.85
|
| Rate for Payer: Humana Medicare |
$12.09
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$11.85
|
| Rate for Payer: United Healthcare Commercial |
$15.01
|
| Rate for Payer: United Healthcare Medicare Advantage |
$11.85
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$11.85
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$9.48
|
| Rate for Payer: Wellcare Medicare |
$10.66
|
|
|
LUPUS ANTICOAGULANT REFLEX
|
Facility
|
IP
|
$23.95
|
|
|
Service Code
|
HCPCS 85613
|
| Hospital Charge Code |
40629224
|
|
Hospital Revenue Code
|
300
|
| Rate for Payer: Cash Price |
$9.58
|
|
|
LUPUS ANTICOAGULANT REFLEX
|
Facility
|
OP
|
$23.95
|
|
|
Service Code
|
HCPCS 85613
|
| Hospital Charge Code |
40629224
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$6.71 |
| Max. Negotiated Rate |
$17.96 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$13.17
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$9.58
|
| Rate for Payer: Aetna Government |
$9.58
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$6.71
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$6.71
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$6.71
|
| Rate for Payer: Brighton Health Commercial |
$17.96
|
| Rate for Payer: Cash Price |
$9.58
|
| Rate for Payer: Cash Price |
$9.58
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$9.58
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$15.22
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$12.88
|
| Rate for Payer: Elderplan Medicare Advantage |
$9.58
|
| Rate for Payer: EmblemHealth Commercial |
$9.58
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$8.14
|
| Rate for Payer: Fidelis Essential Plan QHP |
$8.53
|
| Rate for Payer: Fidelis Medicare Advantage |
$9.58
|
| Rate for Payer: Fidelis Qualified Health Plan |
$8.53
|
| Rate for Payer: Group Health Inc Commercial |
$9.58
|
| Rate for Payer: Group Health Inc Medicare |
$9.58
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$11.98
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$9.58
|
| Rate for Payer: Healthfirst Medicare Advantage |
$9.58
|
| Rate for Payer: Healthfirst QHP |
$9.58
|
| Rate for Payer: Humana Medicare |
$9.77
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$9.58
|
| Rate for Payer: United Healthcare Commercial |
$12.12
|
| Rate for Payer: United Healthcare Medicare Advantage |
$9.58
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$9.58
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$7.66
|
| Rate for Payer: Wellcare Medicare |
$8.62
|
|
|
LUPUS DRVVT CONFIRM
|
Facility
|
OP
|
$44.95
|
|
|
Service Code
|
HCPCS 85597
|
| Hospital Charge Code |
30305753
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$12.59 |
| Max. Negotiated Rate |
$33.71 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$24.72
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$17.98
|
| Rate for Payer: Aetna Government |
$17.98
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$12.59
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$12.59
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$12.59
|
| Rate for Payer: Brighton Health Commercial |
$33.71
|
| Rate for Payer: Cash Price |
$17.98
|
| Rate for Payer: Cash Price |
$17.98
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$17.98
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$28.59
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$24.19
|
| Rate for Payer: Elderplan Medicare Advantage |
$17.98
|
| Rate for Payer: EmblemHealth Commercial |
$17.98
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$15.28
|
| Rate for Payer: Fidelis Essential Plan QHP |
$16.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$17.98
|
| Rate for Payer: Fidelis Qualified Health Plan |
$16.00
|
| Rate for Payer: Group Health Inc Commercial |
$17.98
|
| Rate for Payer: Group Health Inc Medicare |
$17.98
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$22.48
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$17.98
|
| Rate for Payer: Healthfirst Medicare Advantage |
$17.98
|
| Rate for Payer: Healthfirst QHP |
$17.98
|
| Rate for Payer: Humana Medicare |
$18.34
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$17.98
|
| Rate for Payer: United Healthcare Commercial |
$22.77
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.98
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$17.98
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$14.38
|
| Rate for Payer: Wellcare Medicare |
$16.18
|
|
|
LUPUS DRVVT CONFIRM
|
Facility
|
IP
|
$44.95
|
|
|
Service Code
|
HCPCS 85597
|
| Hospital Charge Code |
30305753
|
|
Hospital Revenue Code
|
305
|
| Rate for Payer: Cash Price |
$17.98
|
|
|
LUPUS, HEX PHASE NEUT
|
Facility
|
IP
|
$44.95
|
|
|
Service Code
|
HCPCS 85598
|
| Hospital Charge Code |
30305802
|
|
Hospital Revenue Code
|
300
|
| Rate for Payer: Cash Price |
$17.98
|
|
|
LUPUS, HEX PHASE NEUT
|
Facility
|
OP
|
$44.95
|
|
|
Service Code
|
HCPCS 85598
|
| Hospital Charge Code |
30305802
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.59 |
| Max. Negotiated Rate |
$33.71 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$24.72
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$17.98
|
| Rate for Payer: Aetna Government |
$17.98
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$12.59
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$12.59
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$12.59
|
| Rate for Payer: Brighton Health Commercial |
$33.71
|
| Rate for Payer: Cash Price |
$17.98
|
| Rate for Payer: Cash Price |
$17.98
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$17.98
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$28.59
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$24.19
|
| Rate for Payer: Elderplan Medicare Advantage |
$17.98
|
| Rate for Payer: EmblemHealth Commercial |
$17.98
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$15.28
|
| Rate for Payer: Fidelis Essential Plan QHP |
$16.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$17.98
|
| Rate for Payer: Fidelis Qualified Health Plan |
$16.00
|
| Rate for Payer: Group Health Inc Commercial |
$17.98
|
| Rate for Payer: Group Health Inc Medicare |
$17.98
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$22.48
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$17.98
|
| Rate for Payer: Healthfirst Medicare Advantage |
$17.98
|
| Rate for Payer: Healthfirst QHP |
$17.98
|
| Rate for Payer: Humana Medicare |
$18.34
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$17.98
|
| Rate for Payer: United Healthcare Commercial |
$22.77
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.98
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$17.98
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$14.38
|
| Rate for Payer: Wellcare Medicare |
$16.18
|
|
|
LURASIDONE HCL 20 MG PO TABS [113587]
|
Facility
|
OP
|
$56.75
|
|
|
Service Code
|
NDC 63402030230
|
| Hospital Charge Code |
63402030230
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.86 |
| Max. Negotiated Rate |
$45.40 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$31.21
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$28.37
|
| Rate for Payer: Aetna Government |
$28.37
|
| Rate for Payer: Brighton Health Commercial |
$42.56
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$45.40
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$38.59
|
| Rate for Payer: Group Health Inc Commercial |
$28.37
|
| Rate for Payer: Group Health Inc Medicare |
$19.86
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$28.37
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$28.37
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$36.89
|
|
|
LURASIDONE HCL 20 MG PO TABS [113587]
|
Facility
|
OP
|
$0.83
|
|
|
Service Code
|
NDC 00904735504
|
| Hospital Charge Code |
00904735504
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$0.67 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.46
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.42
|
| Rate for Payer: Aetna Government |
$0.42
|
| Rate for Payer: Brighton Health Commercial |
$0.62
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.67
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.57
|
| Rate for Payer: Group Health Inc Commercial |
$0.42
|
| Rate for Payer: Group Health Inc Medicare |
$0.29
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.42
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.42
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.54
|
|
|
LURASIDONE HCL 20 MG PO TABS [113587]
|
Facility
|
OP
|
$51.07
|
|
|
Service Code
|
NDC 68180067006
|
| Hospital Charge Code |
68180067006
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.88 |
| Max. Negotiated Rate |
$40.86 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$28.09
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$25.54
|
| Rate for Payer: Aetna Government |
$25.54
|
| Rate for Payer: Brighton Health Commercial |
$38.30
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$40.86
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$34.73
|
| Rate for Payer: Group Health Inc Commercial |
$25.54
|
| Rate for Payer: Group Health Inc Medicare |
$17.88
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$25.54
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$25.54
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$33.20
|
|
|
LURASIDONE HCL 40 MG PO TABS [107668]
|
Facility
|
OP
|
$56.75
|
|
|
Service Code
|
NDC 63402030430
|
| Hospital Charge Code |
63402030430
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.86 |
| Max. Negotiated Rate |
$45.40 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$31.21
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$28.37
|
| Rate for Payer: Aetna Government |
$28.37
|
| Rate for Payer: Brighton Health Commercial |
$42.56
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$45.40
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$38.59
|
| Rate for Payer: Group Health Inc Commercial |
$28.37
|
| Rate for Payer: Group Health Inc Medicare |
$19.86
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$28.37
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$28.37
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$36.89
|
|
|
LURASIDONE HCL 80 MG PO TABS [107669]
|
Facility
|
OP
|
$56.75
|
|
|
Service Code
|
NDC 63402030830
|
| Hospital Charge Code |
63402030830
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.86 |
| Max. Negotiated Rate |
$45.40 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$31.21
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$28.37
|
| Rate for Payer: Aetna Government |
$28.37
|
| Rate for Payer: Brighton Health Commercial |
$42.56
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$45.40
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$38.59
|
| Rate for Payer: Group Health Inc Commercial |
$28.37
|
| Rate for Payer: Group Health Inc Medicare |
$19.86
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$28.37
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$28.37
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$36.89
|
|
|
LURASIDONE TABLET 20MG
|
Facility
|
OP
|
$20.00
|
|
| Hospital Charge Code |
41640356
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.00 |
| Max. Negotiated Rate |
$16.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$11.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$10.00
|
| Rate for Payer: Aetna Government |
$10.00
|
| Rate for Payer: Brighton Health Commercial |
$15.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$16.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$13.60
|
| Rate for Payer: Group Health Inc Commercial |
$10.00
|
| Rate for Payer: Group Health Inc Medicare |
$7.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$10.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$10.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$13.00
|
|
|
LURASIDONE TABLET 20MG
|
Facility
|
OP
|
$20.00
|
|
| Hospital Charge Code |
41650356
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.00 |
| Max. Negotiated Rate |
$16.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$11.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$10.00
|
| Rate for Payer: Aetna Government |
$10.00
|
| Rate for Payer: Brighton Health Commercial |
$15.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$16.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$13.60
|
| Rate for Payer: Group Health Inc Commercial |
$10.00
|
| Rate for Payer: Group Health Inc Medicare |
$7.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$10.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$10.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$13.00
|
|
|
LURASIDONE TABLET 40 MG
|
Facility
|
OP
|
$29.54
|
|
|
Service Code
|
HCPCS C9399
|
| Hospital Charge Code |
41656005
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.34 |
| Max. Negotiated Rate |
$19.20 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$16.25
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$14.77
|
| Rate for Payer: Aetna Government |
$14.77
|
| Rate for Payer: Brighton Health Commercial |
$17.72
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$14.77
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$16.99
|
| Rate for Payer: Group Health Inc Commercial |
$14.77
|
| Rate for Payer: Group Health Inc Medicare |
$10.34
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$14.77
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$14.77
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$19.20
|
|
|
LURASIDONE TABLET 40 MG
|
Facility
|
IP
|
$29.54
|
|
|
Service Code
|
HCPCS C9399
|
| Hospital Charge Code |
41656005
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.77 |
| Max. Negotiated Rate |
$14.77 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$14.77
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$14.77
|
|
|
LURASIDONE TABLET 40MG
|
Facility
|
OP
|
$29.54
|
|
|
Service Code
|
HCPCS C9399
|
| Hospital Charge Code |
41646005
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.34 |
| Max. Negotiated Rate |
$19.20 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$16.25
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$14.77
|
| Rate for Payer: Aetna Government |
$14.77
|
| Rate for Payer: Brighton Health Commercial |
$17.72
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$14.77
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$16.99
|
| Rate for Payer: Group Health Inc Commercial |
$14.77
|
| Rate for Payer: Group Health Inc Medicare |
$10.34
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$14.77
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$14.77
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$19.20
|
|
|
LURASIDONE TABLET 40MG
|
Facility
|
IP
|
$29.54
|
|
|
Service Code
|
HCPCS C9399
|
| Hospital Charge Code |
41646005
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.77 |
| Max. Negotiated Rate |
$14.77 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$14.77
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$14.77
|
|
|
LURASIDONE TABLET 80 MG
|
Facility
|
IP
|
$29.59
|
|
|
Service Code
|
HCPCS C9399
|
| Hospital Charge Code |
41646006
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.80 |
| Max. Negotiated Rate |
$14.80 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$14.80
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$14.80
|
|
