|
CAPS, STANDARD
|
Facility
|
OP
|
$312.50
|
|
| Hospital Charge Code |
64905474
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$109.38 |
| Max. Negotiated Rate |
$250.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$171.88
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$156.25
|
| Rate for Payer: Aetna Government |
$156.25
|
| Rate for Payer: Brighton Health Commercial |
$234.38
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$250.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$212.50
|
| Rate for Payer: Group Health Inc Commercial |
$156.25
|
| Rate for Payer: Group Health Inc Medicare |
$109.38
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$156.25
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$156.25
|
|
|
CAPS- STANDARD
|
Facility
|
OP
|
$250.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
40204586
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$87.50 |
| Max. Negotiated Rate |
$262.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$137.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$134.20
|
| Rate for Payer: Aetna Government |
$134.20
|
| Rate for Payer: Brighton Health Commercial |
$150.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$125.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$143.75
|
| Rate for Payer: EmblemHealth Commercial |
$125.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$262.50
|
| Rate for Payer: Group Health Inc Commercial |
$125.00
|
| Rate for Payer: Group Health Inc Medicare |
$87.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$125.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$125.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$162.50
|
|
|
CAPS- STANDARD
|
Facility
|
IP
|
$250.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
40204586
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$125.00 |
| Max. Negotiated Rate |
$125.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$125.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$125.00
|
|
|
Capsulectomy or capsulotomy; interphalangeal joint, each joint
|
Facility
|
OP
|
$2,915.00
|
|
|
Service Code
|
CPT 26525
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,301.03 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,134.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,858.61
|
| Rate for Payer: Aetna Government |
$1,858.61
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$1,301.03
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$1,301.03
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$1,301.03
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,858.61
|
| 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 |
$1,858.61
|
| Rate for Payer: EmblemHealth Commercial |
$1,505.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$1,579.82
|
| Rate for Payer: Fidelis Essential Plan QHP |
$1,654.16
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,858.61
|
| Rate for Payer: Fidelis Qualified Health Plan |
$1,654.16
|
| Rate for Payer: Group Health Inc Commercial |
$1,858.61
|
| Rate for Payer: Group Health Inc Medicare |
$1,858.61
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,858.61
|
| Rate for Payer: Healthfirst Medicare Advantage |
$1,579.82
|
| Rate for Payer: Healthfirst QHP |
$1,858.61
|
| Rate for Payer: Humana Medicare |
$1,895.78
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,858.61
|
| Rate for Payer: United Healthcare Commercial |
$1,409.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,858.61
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,858.61
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$1,486.89
|
| Rate for Payer: Wellcare Medicare |
$1,765.68
|
|
|
Capsulorrhaphy or reconstruction, wrist, open (eg, capsulodesis, ligament repair, tendon transfer or graft) (includes synovectomy, capsulotomy and open reduction) for carpal instability
|
Facility
|
OP
|
$8,438.58
|
|
|
Service Code
|
CPT 25320
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,505.00 |
| Max. Negotiated Rate |
$8,438.58 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,134.00
|
| 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 |
$2,683.00
|
| 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
|
|
|
CAPSULOTOMY
|
Facility
|
OP
|
$3,699.39
|
|
|
Service Code
|
HCPCS 27036
|
| Hospital Charge Code |
40032795
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,040.31 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,034.66
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,040.31
|
| Rate for Payer: Aetna Government |
$1,040.31
|
| Rate for Payer: Brighton Health Commercial |
$2,774.54
|
| 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: EmblemHealth Commercial |
$1,505.00
|
| Rate for Payer: Group Health Inc Commercial |
$1,849.70
|
| Rate for Payer: Group Health Inc Medicare |
$1,294.79
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,849.70
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,849.70
|
| Rate for Payer: United Healthcare Commercial |
$2,683.00
|
|
|
Capsulotomy; metatarsophalangeal joint, with or without tenorrhaphy, each joint (separate procedure)
|
Facility
|
OP
|
$3,818.01
|
|
|
Service Code
|
CPT 28270
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,468.00 |
| Max. Negotiated Rate |
$3,818.01 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,134.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3,743.15
|
| Rate for Payer: Aetna Government |
$3,743.15
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$2,620.20
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$2,620.20
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$2,620.20
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$3,743.15
|
| 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 |
$3,743.15
|
| Rate for Payer: EmblemHealth Commercial |
$1,505.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$3,181.68
|
| Rate for Payer: Fidelis Essential Plan QHP |
$3,331.40
|
| Rate for Payer: Fidelis Medicare Advantage |
$3,743.15
|
| Rate for Payer: Fidelis Qualified Health Plan |
$3,331.40
|
| Rate for Payer: Group Health Inc Commercial |
$3,743.15
|
| Rate for Payer: Group Health Inc Medicare |
$3,743.15
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$3,743.15
|
| Rate for Payer: Healthfirst Medicare Advantage |
$3,181.68
|
| Rate for Payer: Healthfirst QHP |
$3,743.15
|
| Rate for Payer: Humana Medicare |
$3,818.01
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$3,743.15
|
| Rate for Payer: United Healthcare Commercial |
$1,468.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,743.15
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3,743.15
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$2,994.52
|
| Rate for Payer: Wellcare Medicare |
$3,555.99
|
|
|
Capsulotomy, midfoot; with tendon lengthening
|
Facility
|
OP
|
$2,915.00
|
|
|
Service Code
|
CPT 28261
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,301.03 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,134.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,858.61
|
| Rate for Payer: Aetna Government |
$1,858.61
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$1,301.03
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$1,301.03
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$1,301.03
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,858.61
|
| 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 |
$1,858.61
|
| Rate for Payer: EmblemHealth Commercial |
$1,505.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$1,579.82
|
| Rate for Payer: Fidelis Essential Plan QHP |
$1,654.16
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,858.61
|
| Rate for Payer: Fidelis Qualified Health Plan |
$1,654.16
|
| Rate for Payer: Group Health Inc Commercial |
$1,858.61
|
| Rate for Payer: Group Health Inc Medicare |
$1,858.61
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,858.61
|
| Rate for Payer: Healthfirst Medicare Advantage |
$1,579.82
|
| Rate for Payer: Healthfirst QHP |
$1,858.61
|
| Rate for Payer: Humana Medicare |
$1,895.78
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,858.61
|
| Rate for Payer: United Healthcare Commercial |
$1,468.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,858.61
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,858.61
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$1,486.89
|
| Rate for Payer: Wellcare Medicare |
$1,765.68
|
|
|
CAPSURE SENSE LEAD
|
Facility
|
IP
|
$1,125.00
|
|
|
Service Code
|
HCPCS C1898
|
| Hospital Charge Code |
66571445
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$562.50 |
| Max. Negotiated Rate |
$562.50 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$562.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$562.50
|
|
|
CAPSURE SENSE LEAD
|
Facility
|
OP
|
$1,125.00
|
|
|
Service Code
|
HCPCS C1898
|
| Hospital Charge Code |
66571445
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$98.92 |
| Max. Negotiated Rate |
$1,181.25 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$618.75
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$98.92
|
| Rate for Payer: Aetna Government |
$98.92
|
| Rate for Payer: Brighton Health Commercial |
$675.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$562.50
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$646.88
|
| Rate for Payer: EmblemHealth Commercial |
$562.50
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,181.25
|
| Rate for Payer: Group Health Inc Commercial |
$562.50
|
| Rate for Payer: Group Health Inc Medicare |
$393.75
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$562.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$562.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$731.25
|
|
|
CAPSURE SENSE SURESCAN LEAD MED
|
Facility
|
OP
|
$1,125.00
|
|
|
Service Code
|
HCPCS C1898
|
| Hospital Charge Code |
66571963
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$98.92 |
| Max. Negotiated Rate |
$1,181.25 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$618.75
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$98.92
|
| Rate for Payer: Aetna Government |
$98.92
|
| Rate for Payer: Brighton Health Commercial |
$675.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$562.50
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$646.88
|
| Rate for Payer: EmblemHealth Commercial |
$562.50
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,181.25
|
| Rate for Payer: Group Health Inc Commercial |
$562.50
|
| Rate for Payer: Group Health Inc Medicare |
$393.75
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$562.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$562.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$731.25
|
|
|
CAPSURE SENSE SURESCAN LEAD MED
|
Facility
|
IP
|
$1,125.00
|
|
|
Service Code
|
HCPCS C1898
|
| Hospital Charge Code |
66571963
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$562.50 |
| Max. Negotiated Rate |
$562.50 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$562.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$562.50
|
|
|
CAP SYRINGE LUER LOCK 25/PK
|
Facility
|
OP
|
$2.26
|
|
| Hospital Charge Code |
64902604
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$0.79 |
| Max. Negotiated Rate |
$1.81 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.24
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.13
|
| Rate for Payer: Aetna Government |
$1.13
|
| Rate for Payer: Brighton Health Commercial |
$1.70
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.81
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.54
|
| Rate for Payer: Group Health Inc Commercial |
$1.13
|
| Rate for Payer: Group Health Inc Medicare |
$0.79
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.13
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.13
|
|
|
CA+PTH INTACT
|
Facility
|
IP
|
$12.90
|
|
|
Service Code
|
HCPCS 82310
|
| Hospital Charge Code |
40609047
|
|
Hospital Revenue Code
|
300
|
| Rate for Payer: Cash Price |
$5.16
|
|
|
CA+PTH INTACT
|
Facility
|
OP
|
$12.90
|
|
|
Service Code
|
HCPCS 82310
|
| Hospital Charge Code |
40609047
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$3.61 |
| Max. Negotiated Rate |
$9.68 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$7.10
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$5.16
|
| Rate for Payer: Aetna Government |
$5.16
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$3.61
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$3.61
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$3.61
|
| Rate for Payer: Brighton Health Commercial |
$9.68
|
| Rate for Payer: Cash Price |
$5.16
|
| Rate for Payer: Cash Price |
$5.16
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$5.16
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$8.19
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$6.93
|
| Rate for Payer: Elderplan Medicare Advantage |
$5.16
|
| Rate for Payer: EmblemHealth Commercial |
$5.16
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$4.39
|
| Rate for Payer: Fidelis Essential Plan QHP |
$4.59
|
| Rate for Payer: Fidelis Medicare Advantage |
$5.16
|
| Rate for Payer: Fidelis Qualified Health Plan |
$4.59
|
| Rate for Payer: Group Health Inc Commercial |
$5.16
|
| Rate for Payer: Group Health Inc Medicare |
$5.16
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$6.45
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$5.16
|
| Rate for Payer: Healthfirst Medicare Advantage |
$5.16
|
| Rate for Payer: Healthfirst QHP |
$5.16
|
| Rate for Payer: Humana Medicare |
$5.26
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$5.16
|
| Rate for Payer: United Healthcare Commercial |
$6.53
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5.16
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$5.16
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$4.13
|
| Rate for Payer: Wellcare Medicare |
$4.64
|
|
|
CAPTOPRIL 12.5 MG PO TABS [9401]
|
Facility
|
OP
|
$1.56
|
|
|
Service Code
|
NDC 00143117101
|
| Hospital Charge Code |
00143117101
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$1.25 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.86
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.78
|
| Rate for Payer: Aetna Government |
$0.78
|
| Rate for Payer: Brighton Health Commercial |
$1.17
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.25
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.06
|
| Rate for Payer: Group Health Inc Commercial |
$0.78
|
| Rate for Payer: Group Health Inc Medicare |
$0.55
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.78
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.78
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.01
|
|
|
CAPTOPRIL 12.5 MG PO TABS [9401]
|
Facility
|
OP
|
$1.70
|
|
|
Service Code
|
NDC 00904710561
|
| Hospital Charge Code |
00904710561
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$1.36 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.93
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.85
|
| Rate for Payer: Aetna Government |
$0.85
|
| Rate for Payer: Brighton Health Commercial |
$1.27
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.36
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.15
|
| Rate for Payer: Group Health Inc Commercial |
$0.85
|
| Rate for Payer: Group Health Inc Medicare |
$0.59
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.85
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.85
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.10
|
|
|
CAPTOPRIL 12.5 MG TAB
|
Facility
|
OP
|
$1.00
|
|
| Hospital Charge Code |
41654297
|
|
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
|
|
|
CAPTOPRIL 12.5 MG TAB
|
Facility
|
OP
|
$1.00
|
|
| Hospital Charge Code |
41644297
|
|
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
|
|
|
CAPTOPRIL 25 MG TAB
|
Facility
|
OP
|
$0.11
|
|
| Hospital Charge Code |
41653393
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.06
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.06
|
| Rate for Payer: Aetna Government |
$0.06
|
| Rate for Payer: Brighton Health Commercial |
$0.08
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.09
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.07
|
| Rate for Payer: Group Health Inc Commercial |
$0.06
|
| Rate for Payer: Group Health Inc Medicare |
$0.04
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.06
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.06
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.07
|
|
|
CAPTOPRIL 25 MG TAB
|
Facility
|
OP
|
$0.11
|
|
| Hospital Charge Code |
41643393
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.06
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.06
|
| Rate for Payer: Aetna Government |
$0.06
|
| Rate for Payer: Brighton Health Commercial |
$0.08
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.09
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.07
|
| Rate for Payer: Group Health Inc Commercial |
$0.06
|
| Rate for Payer: Group Health Inc Medicare |
$0.04
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.06
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.06
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.07
|
|
|
CAPTOPRIL 50 MG TAB
|
Facility
|
OP
|
$0.03
|
|
| Hospital Charge Code |
41653394
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.02
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.02
|
| Rate for Payer: Aetna Government |
$0.02
|
| Rate for Payer: Brighton Health Commercial |
$0.02
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.02
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.02
|
| Rate for Payer: Group Health Inc Commercial |
$0.02
|
| Rate for Payer: Group Health Inc Medicare |
$0.01
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.02
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.02
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.02
|
|
|
CAPTOPRIL 50 MG TAB
|
Facility
|
OP
|
$0.03
|
|
| Hospital Charge Code |
41643394
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.02
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.02
|
| Rate for Payer: Aetna Government |
$0.02
|
| Rate for Payer: Brighton Health Commercial |
$0.02
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.02
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.02
|
| Rate for Payer: Group Health Inc Commercial |
$0.02
|
| Rate for Payer: Group Health Inc Medicare |
$0.01
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.02
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.02
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.02
|
|
|
CARBACHOL 0.01% INTRAOCULAR INJ
|
Facility
|
OP
|
$22.00
|
|
| Hospital Charge Code |
41641650
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.70 |
| Max. Negotiated Rate |
$17.60 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$12.10
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$11.00
|
| Rate for Payer: Aetna Government |
$11.00
|
| Rate for Payer: Brighton Health Commercial |
$16.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$17.60
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$14.96
|
| Rate for Payer: Group Health Inc Commercial |
$11.00
|
| Rate for Payer: Group Health Inc Medicare |
$7.70
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$11.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$11.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$14.30
|
|
|
CARBACHOL 0.01% INTRAOCULAR INJ
|
Facility
|
OP
|
$22.00
|
|
| Hospital Charge Code |
41651650
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.70 |
| Max. Negotiated Rate |
$17.60 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$12.10
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$11.00
|
| Rate for Payer: Aetna Government |
$11.00
|
| Rate for Payer: Brighton Health Commercial |
$16.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$17.60
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$14.96
|
| Rate for Payer: Group Health Inc Commercial |
$11.00
|
| Rate for Payer: Group Health Inc Medicare |
$7.70
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$11.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$11.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$14.30
|
|
