|
LURASIDONE TABLET 80 MG
|
Facility
|
IP
|
$29.59
|
|
|
Service Code
|
HCPCS C9399
|
| Hospital Charge Code |
41656006
|
|
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
|
|
|
LURASIDONE TABLET 80 MG
|
Facility
|
OP
|
$29.59
|
|
|
Service Code
|
HCPCS C9399
|
| Hospital Charge Code |
41656006
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.36 |
| Max. Negotiated Rate |
$19.23 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$16.27
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$14.80
|
| Rate for Payer: Aetna Government |
$14.80
|
| Rate for Payer: Brighton Health Commercial |
$17.75
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$14.80
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$17.01
|
| Rate for Payer: Group Health Inc Commercial |
$14.80
|
| Rate for Payer: Group Health Inc Medicare |
$10.36
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$14.80
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$14.80
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$19.23
|
|
|
LURASIDONE TABLET 80 MG
|
Facility
|
OP
|
$29.59
|
|
|
Service Code
|
HCPCS C9399
|
| Hospital Charge Code |
41646006
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.36 |
| Max. Negotiated Rate |
$19.23 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$16.27
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$14.80
|
| Rate for Payer: Aetna Government |
$14.80
|
| Rate for Payer: Brighton Health Commercial |
$17.75
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$14.80
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$17.01
|
| Rate for Payer: Group Health Inc Commercial |
$14.80
|
| Rate for Payer: Group Health Inc Medicare |
$10.36
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$14.80
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$14.80
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$19.23
|
|
|
LUSPATERCEPT-AAMT 75 MG SC SOLR [170336]
|
Facility
|
OP
|
$13,953.20
|
|
|
Service Code
|
HCPCS J0896
|
| Hospital Charge Code |
59572077501
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$27.98 |
| Max. Negotiated Rate |
$11,162.56 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$7,674.26
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$39.97
|
| Rate for Payer: Aetna Government |
$39.97
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$27.98
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$27.98
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$27.98
|
| Rate for Payer: Brighton Health Commercial |
$10,464.90
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$39.97
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$11,162.56
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$9,488.18
|
| Rate for Payer: Elderplan Medicare Advantage |
$39.97
|
| Rate for Payer: EmblemHealth Commercial |
$39.97
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$33.98
|
| Rate for Payer: Fidelis Essential Plan QHP |
$35.57
|
| Rate for Payer: Fidelis Medicare Advantage |
$39.97
|
| Rate for Payer: Fidelis Qualified Health Plan |
$35.57
|
| Rate for Payer: Group Health Inc Commercial |
$39.97
|
| Rate for Payer: Group Health Inc Medicare |
$39.97
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$6,976.60
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$39.97
|
| Rate for Payer: Healthfirst Medicare Advantage |
$33.98
|
| Rate for Payer: Healthfirst QHP |
$39.97
|
| Rate for Payer: Humana Medicare |
$40.77
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$39.98
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$42.38
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$42.38
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$42.38
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$39.97
|
| Rate for Payer: United Healthcare Medicare Advantage |
$39.97
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$9,069.58
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$31.98
|
| Rate for Payer: Wellcare Medicare |
$37.97
|
|
|
LUSPATERCEPT POWDER
|
Facility
|
OP
|
$34.41
|
|
|
Service Code
|
HCPCS J0896
|
| Hospital Charge Code |
41640363
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.20 |
| Max. Negotiated Rate |
$42.38 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$18.93
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$39.97
|
| Rate for Payer: Aetna Government |
$39.97
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$27.98
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$27.98
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$27.98
|
| Rate for Payer: Brighton Health Commercial |
$20.65
|
| Rate for Payer: Cash Price |
$39.97
|
| Rate for Payer: Cash Price |
$39.97
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$39.97
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$17.20
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$19.79
|
| Rate for Payer: Elderplan Medicare Advantage |
$39.97
|
| Rate for Payer: EmblemHealth Commercial |
$39.97
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$39.97
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$39.97
|
| Rate for Payer: Fidelis Essential Plan QHP |
$41.97
|
| Rate for Payer: Fidelis Medicare Advantage |
$39.97
|
| Rate for Payer: Fidelis Qualified Health Plan |
$41.97
|
| Rate for Payer: Group Health Inc Commercial |
$39.97
|
| Rate for Payer: Group Health Inc Medicare |
$39.97
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$17.20
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$17.20
|
| Rate for Payer: Healthfirst Medicare Advantage |
$33.98
|
| Rate for Payer: Healthfirst QHP |
$39.97
|
| Rate for Payer: Humana Medicare |
$40.77
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$39.97
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$42.38
|
| Rate for Payer: SOMOS Essential |
$42.38
|
| Rate for Payer: United Healthcare Commercial |
$38.47
|
| Rate for Payer: United Healthcare Medicare Advantage |
$39.97
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$22.37
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$31.98
|
| Rate for Payer: Wellcare Medicare |
$37.97
|
|
|
LUSPATERCEPT POWDER
|
Facility
|
IP
|
$34.41
|
|
|
Service Code
|
HCPCS J0896
|
| Hospital Charge Code |
41640363
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.20 |
| Max. Negotiated Rate |
$17.20 |
| Rate for Payer: Cash Price |
$39.97
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$17.20
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$17.20
|
|
|
LUSPATERCEPT POWDER
|
Facility
|
OP
|
$34.41
|
|
|
Service Code
|
HCPCS J0896
|
| Hospital Charge Code |
41650363
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.20 |
| Max. Negotiated Rate |
$42.38 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$18.93
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$39.97
|
| Rate for Payer: Aetna Government |
$39.97
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$27.98
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$27.98
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$27.98
|
| Rate for Payer: Brighton Health Commercial |
$20.65
|
| Rate for Payer: Cash Price |
$39.97
|
| Rate for Payer: Cash Price |
$39.97
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$39.97
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$17.20
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$19.79
|
| Rate for Payer: Elderplan Medicare Advantage |
$39.97
|
| Rate for Payer: EmblemHealth Commercial |
$39.97
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$39.97
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$39.97
|
| Rate for Payer: Fidelis Essential Plan QHP |
$41.97
|
| Rate for Payer: Fidelis Medicare Advantage |
$39.97
|
| Rate for Payer: Fidelis Qualified Health Plan |
$41.97
|
| Rate for Payer: Group Health Inc Commercial |
$39.97
|
| Rate for Payer: Group Health Inc Medicare |
$39.97
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$17.20
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$17.20
|
| Rate for Payer: Healthfirst Medicare Advantage |
$33.98
|
| Rate for Payer: Healthfirst QHP |
$39.97
|
| Rate for Payer: Humana Medicare |
$40.77
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$39.97
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$42.38
|
| Rate for Payer: SOMOS Essential |
$42.38
|
| Rate for Payer: United Healthcare Commercial |
$38.47
|
| Rate for Payer: United Healthcare Medicare Advantage |
$39.97
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$22.37
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$31.98
|
| Rate for Payer: Wellcare Medicare |
$37.97
|
|
|
LUSPATERCEPT POWDER
|
Facility
|
IP
|
$34.41
|
|
|
Service Code
|
HCPCS J0896
|
| Hospital Charge Code |
41650363
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.20 |
| Max. Negotiated Rate |
$17.20 |
| Rate for Payer: Cash Price |
$39.97
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$17.20
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$17.20
|
|
|
LUTEINIZING HORMONE(LH), S
|
Facility
|
OP
|
$46.30
|
|
|
Service Code
|
HCPCS 83002
|
| Hospital Charge Code |
40609081
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.96 |
| Max. Negotiated Rate |
$34.72 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$25.46
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$18.52
|
| Rate for Payer: Aetna Government |
$18.52
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$12.96
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$12.96
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$12.96
|
| Rate for Payer: Brighton Health Commercial |
$34.72
|
| Rate for Payer: Cash Price |
$18.52
|
| Rate for Payer: Cash Price |
$18.52
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$18.52
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$29.44
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$24.92
|
| Rate for Payer: Elderplan Medicare Advantage |
$18.52
|
| Rate for Payer: EmblemHealth Commercial |
$18.52
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$15.74
|
| Rate for Payer: Fidelis Essential Plan QHP |
$16.48
|
| Rate for Payer: Fidelis Medicare Advantage |
$18.52
|
| Rate for Payer: Fidelis Qualified Health Plan |
$16.48
|
| Rate for Payer: Group Health Inc Commercial |
$18.52
|
| Rate for Payer: Group Health Inc Medicare |
$18.52
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$23.15
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$18.52
|
| Rate for Payer: Healthfirst Medicare Advantage |
$18.52
|
| Rate for Payer: Healthfirst QHP |
$18.52
|
| Rate for Payer: Humana Medicare |
$18.89
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$18.52
|
| Rate for Payer: United Healthcare Commercial |
$23.45
|
| Rate for Payer: United Healthcare Medicare Advantage |
$18.52
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$18.52
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$14.82
|
| Rate for Payer: Wellcare Medicare |
$16.67
|
|
|
LUTEINIZING HORMONE(LH), S
|
Facility
|
IP
|
$46.30
|
|
|
Service Code
|
HCPCS 83002
|
| Hospital Charge Code |
40609081
|
|
Hospital Revenue Code
|
300
|
| Rate for Payer: Cash Price |
$18.52
|
|
|
LUTONIX DRG CT BL 4MMX100MMX130MM
|
Facility
|
OP
|
$3,200.00
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
40004736
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,120.00 |
| Max. Negotiated Rate |
$3,360.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,760.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,600.00
|
| Rate for Payer: Aetna Government |
$1,600.00
|
| Rate for Payer: Brighton Health Commercial |
$1,920.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,600.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,840.00
|
| Rate for Payer: EmblemHealth Commercial |
$1,600.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$3,360.00
|
| Rate for Payer: Group Health Inc Commercial |
$1,600.00
|
| Rate for Payer: Group Health Inc Medicare |
$1,120.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,600.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,600.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2,080.00
|
|
|
LUTONIX DRG CT BL 4MMX100MMX130MM
|
Facility
|
IP
|
$3,200.00
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
40004736
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,600.00 |
| Max. Negotiated Rate |
$1,600.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,600.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,600.00
|
|
|
LUTONIX DRG CT BL 4MMX100MMX75CM
|
Facility
|
IP
|
$3,200.00
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
40004802
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,600.00 |
| Max. Negotiated Rate |
$1,600.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,600.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,600.00
|
|
|
LUTONIX DRG CT BL 4MMX100MMX75CM
|
Facility
|
OP
|
$3,200.00
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
40004802
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,120.00 |
| Max. Negotiated Rate |
$3,360.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,760.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,600.00
|
| Rate for Payer: Aetna Government |
$1,600.00
|
| Rate for Payer: Brighton Health Commercial |
$1,920.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,600.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,840.00
|
| Rate for Payer: EmblemHealth Commercial |
$1,600.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$3,360.00
|
| Rate for Payer: Group Health Inc Commercial |
$1,600.00
|
| Rate for Payer: Group Health Inc Medicare |
$1,120.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,600.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,600.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2,080.00
|
|
|
LUTONIX DRG CT BL 4MMX120MMX130MM
|
Facility
|
OP
|
$3,500.00
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
40004737
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,225.00 |
| Max. Negotiated Rate |
$3,675.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,925.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,750.00
|
| Rate for Payer: Aetna Government |
$1,750.00
|
| Rate for Payer: Brighton Health Commercial |
$2,100.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,750.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,012.50
|
| Rate for Payer: EmblemHealth Commercial |
$1,750.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$3,675.00
|
| Rate for Payer: Group Health Inc Commercial |
$1,750.00
|
| Rate for Payer: Group Health Inc Medicare |
$1,225.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,750.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,750.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2,275.00
|
|
|
LUTONIX DRG CT BL 4MMX120MMX130MM
|
Facility
|
IP
|
$3,500.00
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
40004737
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,750.00 |
| Max. Negotiated Rate |
$1,750.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,750.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,750.00
|
|
|
LUTONIX DRG CT BL 4MMX150MMX130MM
|
Facility
|
IP
|
$3,800.00
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
40004738
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,900.00 |
| Max. Negotiated Rate |
$1,900.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,900.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,900.00
|
|
|
LUTONIX DRG CT BL 4MMX150MMX130MM
|
Facility
|
OP
|
$3,800.00
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
40004738
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,330.00 |
| Max. Negotiated Rate |
$3,990.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,090.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,900.00
|
| Rate for Payer: Aetna Government |
$1,900.00
|
| Rate for Payer: Brighton Health Commercial |
$2,280.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,900.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,185.00
|
| Rate for Payer: EmblemHealth Commercial |
$1,900.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$3,990.00
|
| Rate for Payer: Group Health Inc Commercial |
$1,900.00
|
| Rate for Payer: Group Health Inc Medicare |
$1,330.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,900.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,900.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2,470.00
|
|
|
LUTONIX DRG CT BL 4MMX40MMX75CM
|
Facility
|
OP
|
$3,200.00
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
40004799
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,120.00 |
| Max. Negotiated Rate |
$3,360.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,760.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,600.00
|
| Rate for Payer: Aetna Government |
$1,600.00
|
| Rate for Payer: Brighton Health Commercial |
$1,920.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,600.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,840.00
|
| Rate for Payer: EmblemHealth Commercial |
$1,600.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$3,360.00
|
| Rate for Payer: Group Health Inc Commercial |
$1,600.00
|
| Rate for Payer: Group Health Inc Medicare |
$1,120.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,600.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,600.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2,080.00
|
|
|
LUTONIX DRG CT BL 4MMX40MMX75CM
|
Facility
|
IP
|
$3,200.00
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
40004799
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,600.00 |
| Max. Negotiated Rate |
$1,600.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,600.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,600.00
|
|
|
LUTONIX DRG CT BL 4MMX60MMX75CM
|
Facility
|
IP
|
$3,200.00
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
40004800
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,600.00 |
| Max. Negotiated Rate |
$1,600.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,600.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,600.00
|
|
|
LUTONIX DRG CT BL 4MMX60MMX75CM
|
Facility
|
OP
|
$3,200.00
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
40004800
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,120.00 |
| Max. Negotiated Rate |
$3,360.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,760.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,600.00
|
| Rate for Payer: Aetna Government |
$1,600.00
|
| Rate for Payer: Brighton Health Commercial |
$1,920.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,600.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,840.00
|
| Rate for Payer: EmblemHealth Commercial |
$1,600.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$3,360.00
|
| Rate for Payer: Group Health Inc Commercial |
$1,600.00
|
| Rate for Payer: Group Health Inc Medicare |
$1,120.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,600.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,600.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2,080.00
|
|
|
LUTONIX DRG CT BL 4MMX80MMX130MM
|
Facility
|
OP
|
$3,200.00
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
40004735
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,120.00 |
| Max. Negotiated Rate |
$3,360.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,760.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,600.00
|
| Rate for Payer: Aetna Government |
$1,600.00
|
| Rate for Payer: Brighton Health Commercial |
$1,920.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,600.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,840.00
|
| Rate for Payer: EmblemHealth Commercial |
$1,600.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$3,360.00
|
| Rate for Payer: Group Health Inc Commercial |
$1,600.00
|
| Rate for Payer: Group Health Inc Medicare |
$1,120.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,600.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,600.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2,080.00
|
|
|
LUTONIX DRG CT BL 4MMX80MMX130MM
|
Facility
|
IP
|
$3,200.00
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
40004735
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,600.00 |
| Max. Negotiated Rate |
$1,600.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,600.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,600.00
|
|
|
LUTONIX DRG CT BL 4MMX80MMX75CM
|
Facility
|
OP
|
$3,200.00
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
40004801
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,120.00 |
| Max. Negotiated Rate |
$3,360.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,760.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,600.00
|
| Rate for Payer: Aetna Government |
$1,600.00
|
| Rate for Payer: Brighton Health Commercial |
$1,920.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,600.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,840.00
|
| Rate for Payer: EmblemHealth Commercial |
$1,600.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$3,360.00
|
| Rate for Payer: Group Health Inc Commercial |
$1,600.00
|
| Rate for Payer: Group Health Inc Medicare |
$1,120.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,600.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,600.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2,080.00
|
|
