|
CC BMS AB VISION ML RX2.75MMX23MM
|
Facility
IP
|
$1,950.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
66528924
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$975.00 |
| Max. Negotiated Rate |
$975.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$975.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$975.00
|
|
|
CC BMS AB VISION ML RX2.75MMX23MM
|
Facility
OP
|
$1,950.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
66528924
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$398.18 |
| Max. Negotiated Rate |
$2,047.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,072.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$398.18
|
| Rate for Payer: Aetna Government |
$398.18
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$975.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,121.25
|
| Rate for Payer: Fidelis Medicare Advantage |
$2,047.50
|
| Rate for Payer: Group Health Inc Commercial |
$975.00
|
| Rate for Payer: Group Health Inc Medicare |
$682.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$975.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$975.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,267.50
|
|
|
CC BMS AB VISION ML RX2.75MMX28MM
|
Facility
OP
|
$1,950.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
66528925
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$398.18 |
| Max. Negotiated Rate |
$2,047.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,072.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$398.18
|
| Rate for Payer: Aetna Government |
$398.18
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$975.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,121.25
|
| Rate for Payer: Fidelis Medicare Advantage |
$2,047.50
|
| Rate for Payer: Group Health Inc Commercial |
$975.00
|
| Rate for Payer: Group Health Inc Medicare |
$682.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$975.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$975.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,267.50
|
|
|
CC BMS AB VISION ML RX2.75MMX28MM
|
Facility
IP
|
$1,950.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
66528925
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$975.00 |
| Max. Negotiated Rate |
$975.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$975.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$975.00
|
|
|
CC BMS AB VISION ML RX2.75MMX8MM
|
Facility
OP
|
$1,950.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
66528926
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$398.18 |
| Max. Negotiated Rate |
$2,047.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,072.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$398.18
|
| Rate for Payer: Aetna Government |
$398.18
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$975.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,121.25
|
| Rate for Payer: Fidelis Medicare Advantage |
$2,047.50
|
| Rate for Payer: Group Health Inc Commercial |
$975.00
|
| Rate for Payer: Group Health Inc Medicare |
$682.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$975.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$975.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,267.50
|
|
|
CC BMS AB VISION ML RX2.75MMX8MM
|
Facility
IP
|
$1,950.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
66528926
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$975.00 |
| Max. Negotiated Rate |
$975.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$975.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$975.00
|
|
|
CC BMS AB VISION ML RX 2.75X15MM
|
Facility
OP
|
$1,950.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
66528922
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$398.18 |
| Max. Negotiated Rate |
$2,047.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,072.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$398.18
|
| Rate for Payer: Aetna Government |
$398.18
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$975.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,121.25
|
| Rate for Payer: Fidelis Medicare Advantage |
$2,047.50
|
| Rate for Payer: Group Health Inc Commercial |
$975.00
|
| Rate for Payer: Group Health Inc Medicare |
$682.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$975.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$975.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,267.50
|
|
|
CC BMS AB VISION ML RX 2.75X15MM
|
Facility
IP
|
$1,950.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
66528922
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$975.00 |
| Max. Negotiated Rate |
$975.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$975.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$975.00
|
|
|
CC BMS AB VISION ML RX3.0MMX12MM
|
Facility
IP
|
$1,950.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
66528927
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$975.00 |
| Max. Negotiated Rate |
$975.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$975.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$975.00
|
|
|
CC BMS AB VISION ML RX3.0MMX12MM
|
Facility
OP
|
$1,950.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
66528927
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$398.18 |
| Max. Negotiated Rate |
$2,047.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,072.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$398.18
|
| Rate for Payer: Aetna Government |
$398.18
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$975.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,121.25
|
| Rate for Payer: Fidelis Medicare Advantage |
$2,047.50
|
| Rate for Payer: Group Health Inc Commercial |
$975.00
|
| Rate for Payer: Group Health Inc Medicare |
$682.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$975.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$975.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,267.50
|
|
|
CC BMS AB VISION ML RX 3.0MMX15MM
|
Facility
IP
|
$1,950.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
66528928
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$975.00 |
| Max. Negotiated Rate |
$975.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$975.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$975.00
|
|
|
CC BMS AB VISION ML RX 3.0MMX15MM
|
Facility
OP
|
$1,950.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
66528928
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$398.18 |
| Max. Negotiated Rate |
$2,047.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,072.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$398.18
|
| Rate for Payer: Aetna Government |
$398.18
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$975.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,121.25
|
| Rate for Payer: Fidelis Medicare Advantage |
$2,047.50
|
| Rate for Payer: Group Health Inc Commercial |
$975.00
|
| Rate for Payer: Group Health Inc Medicare |
$682.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$975.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$975.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,267.50
|
|
|
CC BMS AB VISION ML RX3.0MMX23MM
|
Facility
IP
|
$1,950.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
66528930
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$975.00 |
| Max. Negotiated Rate |
$975.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$975.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$975.00
|
|
|
CC BMS AB VISION ML RX3.0MMX23MM
|
Facility
OP
|
$1,950.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
66528930
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$398.18 |
| Max. Negotiated Rate |
$2,047.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,072.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$398.18
|
| Rate for Payer: Aetna Government |
$398.18
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$975.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,121.25
|
| Rate for Payer: Fidelis Medicare Advantage |
$2,047.50
|
| Rate for Payer: Group Health Inc Commercial |
$975.00
|
| Rate for Payer: Group Health Inc Medicare |
$682.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$975.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$975.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,267.50
|
|
|
CC BMS AB VISION ML RX3.0MMX28MM
|
Facility
OP
|
$1,950.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
66528931
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$398.18 |
| Max. Negotiated Rate |
$2,047.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,072.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$398.18
|
| Rate for Payer: Aetna Government |
$398.18
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$975.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,121.25
|
| Rate for Payer: Fidelis Medicare Advantage |
$2,047.50
|
| Rate for Payer: Group Health Inc Commercial |
$975.00
|
| Rate for Payer: Group Health Inc Medicare |
$682.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$975.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$975.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,267.50
|
|
|
CC BMS AB VISION ML RX3.0MMX28MM
|
Facility
IP
|
$1,950.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
66528931
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$975.00 |
| Max. Negotiated Rate |
$975.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$975.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$975.00
|
|
|
CC BMS AB VISION ML RX 3.0X8MM
|
Facility
IP
|
$1,950.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
66528932
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$975.00 |
| Max. Negotiated Rate |
$975.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$975.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$975.00
|
|
|
CC BMS AB VISION ML RX 3.0X8MM
|
Facility
OP
|
$1,950.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
66528932
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$398.18 |
| Max. Negotiated Rate |
$2,047.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,072.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$398.18
|
| Rate for Payer: Aetna Government |
$398.18
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$975.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,121.25
|
| Rate for Payer: Fidelis Medicare Advantage |
$2,047.50
|
| Rate for Payer: Group Health Inc Commercial |
$975.00
|
| Rate for Payer: Group Health Inc Medicare |
$682.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$975.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$975.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,267.50
|
|
|
CC BMS AB VISION ML RX3.5MMX15
|
Facility
OP
|
$1,950.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
66528934
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$398.18 |
| Max. Negotiated Rate |
$2,047.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,072.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$398.18
|
| Rate for Payer: Aetna Government |
$398.18
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$975.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,121.25
|
| Rate for Payer: Fidelis Medicare Advantage |
$2,047.50
|
| Rate for Payer: Group Health Inc Commercial |
$975.00
|
| Rate for Payer: Group Health Inc Medicare |
$682.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$975.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$975.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,267.50
|
|
|
CC BMS AB VISION ML RX3.5MMX15
|
Facility
IP
|
$1,950.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
66528934
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$975.00 |
| Max. Negotiated Rate |
$975.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$975.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$975.00
|
|
|
CC BMS AB VISION ML RX 3.5MMX18MM
|
Facility
OP
|
$1,950.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
66528935
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$398.18 |
| Max. Negotiated Rate |
$2,047.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,072.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$398.18
|
| Rate for Payer: Aetna Government |
$398.18
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$975.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,121.25
|
| Rate for Payer: Fidelis Medicare Advantage |
$2,047.50
|
| Rate for Payer: Group Health Inc Commercial |
$975.00
|
| Rate for Payer: Group Health Inc Medicare |
$682.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$975.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$975.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,267.50
|
|
|
CC BMS AB VISION ML RX 3.5MMX18MM
|
Facility
IP
|
$1,950.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
66528935
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$975.00 |
| Max. Negotiated Rate |
$975.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$975.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$975.00
|
|
|
CC BMS AB VISION ML RX 3.5MMX23MM
|
Facility
OP
|
$1,950.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
66528936
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$398.18 |
| Max. Negotiated Rate |
$2,047.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,072.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$398.18
|
| Rate for Payer: Aetna Government |
$398.18
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$975.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,121.25
|
| Rate for Payer: Fidelis Medicare Advantage |
$2,047.50
|
| Rate for Payer: Group Health Inc Commercial |
$975.00
|
| Rate for Payer: Group Health Inc Medicare |
$682.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$975.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$975.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,267.50
|
|
|
CC BMS AB VISION ML RX 3.5MMX23MM
|
Facility
IP
|
$1,950.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
66528936
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$975.00 |
| Max. Negotiated Rate |
$975.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$975.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$975.00
|
|
|
CC BMS AB VISION ML RX3.5MMX28MM
|
Facility
OP
|
$1,950.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
66528937
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$398.18 |
| Max. Negotiated Rate |
$2,047.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,072.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$398.18
|
| Rate for Payer: Aetna Government |
$398.18
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$975.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,121.25
|
| Rate for Payer: Fidelis Medicare Advantage |
$2,047.50
|
| Rate for Payer: Group Health Inc Commercial |
$975.00
|
| Rate for Payer: Group Health Inc Medicare |
$682.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$975.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$975.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,267.50
|
|
