St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

TECHNET TC 99M SULFUR COLLOID CO KIT

Facility

$751.40

Service Code	NDC 4556700301
Hospital Charge Code	4556700301
Hospital Revenue Code	250
Min. Negotiated Rate	$262.99
Max. Negotiated Rate	$601.12
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$413.27
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$375.70
Rate for Payer: Aetna Government	$375.70
Rate for Payer: Brighton Health Commercial	$563.55
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$601.12
Rate for Payer: Cigna LocalPlus Benefit Plan	$510.95
Rate for Payer: EmblemHealth Commercial	$375.70
Rate for Payer: Group Health Inc Commercial	$375.70
Rate for Payer: Group Health Inc Medicare	$262.99
Rate for Payer: Hamaspik Choice Inc Medicaid	$375.70
Rate for Payer: Hamaspik Choice Inc Medicare	$375.70
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$488.41

TECHNET TC 99M SULFUR COLLOID CO KIT

Facility

$751.40

Service Code	NDC 4556700301
Hospital Charge Code	4556700301
Hospital Revenue Code	250
Min. Negotiated Rate	$375.70
Max. Negotiated Rate	$375.70
Rate for Payer: Hamaspik Choice Inc Medicaid	$375.70

TECOVIRIMAT 200 MG/20ML IV SOLN

Facility

$0.00

Service Code	NDC 5007201001
Hospital Charge Code	5007201001
Hospital Revenue Code	258
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.00

TECOVIRIMAT 200 MG/20ML IV SOLN

Facility

$0.00

Service Code	NDC 5007201001
Hospital Charge Code	5007201001
Hospital Revenue Code	258
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.00
Rate for Payer: Aetna Government	$0.00
Rate for Payer: Brighton Health Commercial	$0.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.00
Rate for Payer: EmblemHealth Commercial	$0.00
Rate for Payer: Group Health Inc Commercial	$0.00
Rate for Payer: Group Health Inc Medicare	$0.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.00
Rate for Payer: Hamaspik Choice Inc Medicare	$0.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.00

TEDIZOLID PHOSPHATE 200 MG PO TABS

Facility

$506.25

Service Code	NDC 7200031006
Hospital Charge Code	7200031006
Hospital Revenue Code	250
Min. Negotiated Rate	$253.12
Max. Negotiated Rate	$253.12
Rate for Payer: Hamaspik Choice Inc Medicaid	$253.12

TEDIZOLID PHOSPHATE 200 MG PO TABS

Facility

$506.25

Service Code	NDC 7200031006
Hospital Charge Code	7200031006
Hospital Revenue Code	250
Min. Negotiated Rate	$177.19
Max. Negotiated Rate	$405.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$278.44
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$253.12
Rate for Payer: Aetna Government	$253.12
Rate for Payer: Brighton Health Commercial	$379.69
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$405.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$344.25
Rate for Payer: EmblemHealth Commercial	$253.12
Rate for Payer: Group Health Inc Commercial	$253.12
Rate for Payer: Group Health Inc Medicare	$177.19
Rate for Payer: Hamaspik Choice Inc Medicaid	$253.12
Rate for Payer: Hamaspik Choice Inc Medicare	$253.12
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$329.06

TEMAZEPAM 15 MG PO CAPS

Facility

$0.82

Service Code	NDC 6787714601
Hospital Charge Code	6787714601
Hospital Revenue Code	250
Min. Negotiated Rate	$0.29
Max. Negotiated Rate	$0.65
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.45
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.41
Rate for Payer: Aetna Government	$0.41
Rate for Payer: Brighton Health Commercial	$0.61
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.65
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.55
Rate for Payer: EmblemHealth Commercial	$0.41
Rate for Payer: Group Health Inc Commercial	$0.41
Rate for Payer: Group Health Inc Medicare	$0.29
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.41
Rate for Payer: Hamaspik Choice Inc Medicare	$0.41
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.53

TEMAZEPAM 15 MG PO CAPS

Facility

$0.82

Service Code	NDC 6787714601
Hospital Charge Code	6787714601
Hospital Revenue Code	250
Min. Negotiated Rate	$0.41
Max. Negotiated Rate	$0.41
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.41

TEMAZEPAM 15 MG PO CAPS

Facility

$0.74

Service Code	NDC 0228207610
Hospital Charge Code	0228207610
Hospital Revenue Code	250
Min. Negotiated Rate	$0.26
Max. Negotiated Rate	$0.59
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.40
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.37
Rate for Payer: Aetna Government	$0.37
Rate for Payer: Brighton Health Commercial	$0.55
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.59
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.50
Rate for Payer: EmblemHealth Commercial	$0.37
Rate for Payer: Group Health Inc Commercial	$0.37
Rate for Payer: Group Health Inc Medicare	$0.26
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.37
Rate for Payer: Hamaspik Choice Inc Medicare	$0.37
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.48

TEMAZEPAM 15 MG PO CAPS

Facility

$0.74

Service Code	NDC 0228207610
Hospital Charge Code	0228207610
Hospital Revenue Code	250
Min. Negotiated Rate	$0.37
Max. Negotiated Rate	$0.37
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.37

TEMOZOLOMIDE 100 MG PO CAPS

Facility

$287.77

Service Code	HCPCS J8700
Hospital Charge Code	1672905054
Hospital Revenue Code	250
Min. Negotiated Rate	$143.88
Max. Negotiated Rate	$143.88
Rate for Payer: Hamaspik Choice Inc Medicaid	$143.88

TEMOZOLOMIDE 100 MG PO CAPS

Facility

$287.77

Service Code	HCPCS J8700
Hospital Charge Code	1672905054
Hospital Revenue Code	250
Min. Negotiated Rate	$0.36
Max. Negotiated Rate	$230.21
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$158.27
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.36
Rate for Payer: Aetna Government	$0.36
Rate for Payer: Brighton Health Commercial	$215.82
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$230.21
Rate for Payer: Cigna LocalPlus Benefit Plan	$195.68
Rate for Payer: EmblemHealth Commercial	$143.88
Rate for Payer: Group Health Inc Commercial	$143.88
Rate for Payer: Group Health Inc Medicare	$100.72
Rate for Payer: Hamaspik Choice Inc Medicaid	$143.88
Rate for Payer: Hamaspik Choice Inc Medicare	$143.88
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$0.46
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$187.05

TEMSIROLIMUS 25 MG/ML IV SOLN

Facility

$2.00

Service Code	HCPCS J9330
Hospital Charge Code	0008117901
Hospital Revenue Code	258
Min. Negotiated Rate	$1.00
Max. Negotiated Rate	$1.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.00

TEMSIROLIMUS 25 MG/ML IV SOLN

Facility

$2.00

Service Code	HCPCS J9330
Hospital Charge Code	0008117901
Hospital Revenue Code	258
Min. Negotiated Rate	$1.10
Max. Negotiated Rate	$27.24
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.10
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$26.71
Rate for Payer: Aetna Government	$26.71
Rate for Payer: Affinity Essential Plan 1&2	$18.70
Rate for Payer: Affinity Essential Plan 3&4	$18.70
Rate for Payer: Affinity Medicaid/CHP/HARP	$18.70
Rate for Payer: Brighton Health Commercial	$1.50
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$26.71
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.60
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.36
Rate for Payer: Elderplan Medicare Advantage	$26.71
Rate for Payer: EmblemHealth Commercial	$26.71
Rate for Payer: Fidelis CHP/HARP/Medicaid	$24.04
Rate for Payer: Fidelis Essential Plan Aliesa	$22.70
Rate for Payer: Fidelis Essential Plan QHP	$23.77
Rate for Payer: Fidelis Medicare Advantage	$26.71
Rate for Payer: Fidelis Qualified Health Plan	$23.77
Rate for Payer: Group Health Inc Commercial	$26.71
Rate for Payer: Group Health Inc Medicare	$26.71
Rate for Payer: Hamaspik Choice Inc Medicaid	$26.71
Rate for Payer: Hamaspik Choice Inc Medicare	$26.71
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$26.71
Rate for Payer: Healthfirst Medicare Advantage	$22.70
Rate for Payer: Healthfirst QHP	$26.71
Rate for Payer: Humana Medicare	$27.24
Rate for Payer: Senior Whole Health Medicare Advantage	$26.71
Rate for Payer: United Healthcare Medicare Advantage	$26.71
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.30
Rate for Payer: Wellcare CHP/FHP/Medicaid	$25.37
Rate for Payer: Wellcare Medicare	$25.37

Tendon, muscle & other soft tissue procedures

Facility

$47,841.86

Service Code	APR-DRG 3171
Min. Negotiated Rate	$10,079.00
Max. Negotiated Rate	$47,841.86
Rate for Payer: Affinity Essential Plan 1&2	$47,841.86
Rate for Payer: Affinity Essential Plan 3&4	$47,841.86
Rate for Payer: Affinity Medicaid/CHP/HARP	$21,263.05
Rate for Payer: Amida Care Medicaid	$21,263.05
Rate for Payer: EmblemHealth Essential Plan 1&2	$47,841.86
Rate for Payer: EmblemHealth Essential Plan 3&4	$21,263.05
Rate for Payer: Fidelis CHP/HARP/Medicaid	$21,263.05
Rate for Payer: Fidelis Qualified Health Plan	$25,515.66
Rate for Payer: Hamaspik Choice Inc Medicaid	$21,263.05
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$21,263.05
Rate for Payer: Healthfirst Commercial	$17,202.00
Rate for Payer: Healthfirst Essential Plan	$47,841.86
Rate for Payer: Healthfirst QHP	$10,079.00
Rate for Payer: SOMOS CHP/HARP/Medicaid	$21,263.05
Rate for Payer: SOMOS Essential	$47,841.86
Rate for Payer: United Healthcare Essential Plan 1&2	$47,841.86
Rate for Payer: United Healthcare Essential Plan 3&4	$47,841.86
Rate for Payer: United Healthcare Medicaid	$21,263.05
Rate for Payer: Wellcare CHP/FHP/Medicaid	$21,263.05

Tendon, muscle & other soft tissue procedures

Facility

$57,252.92

Service Code	APR-DRG 3172
Min. Negotiated Rate	$16,179.00
Max. Negotiated Rate	$57,252.92
Rate for Payer: Affinity Essential Plan 1&2	$57,252.92
Rate for Payer: Affinity Essential Plan 3&4	$57,252.92
Rate for Payer: Affinity Medicaid/CHP/HARP	$25,445.74
Rate for Payer: Amida Care Medicaid	$25,445.74
Rate for Payer: EmblemHealth Essential Plan 1&2	$57,252.92
Rate for Payer: EmblemHealth Essential Plan 3&4	$25,445.74
Rate for Payer: Fidelis CHP/HARP/Medicaid	$25,445.74
Rate for Payer: Fidelis Qualified Health Plan	$30,534.89
Rate for Payer: Hamaspik Choice Inc Medicaid	$25,445.74
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$25,445.74
Rate for Payer: Healthfirst Commercial	$27,090.00
Rate for Payer: Healthfirst Essential Plan	$57,252.92
Rate for Payer: Healthfirst QHP	$16,179.00
Rate for Payer: SOMOS CHP/HARP/Medicaid	$25,445.74
Rate for Payer: SOMOS Essential	$57,252.92
Rate for Payer: United Healthcare Essential Plan 1&2	$57,252.92
Rate for Payer: United Healthcare Essential Plan 3&4	$57,252.92
Rate for Payer: United Healthcare Medicaid	$25,445.74
Rate for Payer: Wellcare CHP/FHP/Medicaid	$25,445.74

Tendon, muscle & other soft tissue procedures

Facility

$143,134.24

Service Code	APR-DRG 3174
Min. Negotiated Rate	$63,615.22
Max. Negotiated Rate	$143,134.24
Rate for Payer: Affinity Essential Plan 1&2	$143,134.24
Rate for Payer: Affinity Essential Plan 3&4	$143,134.24
Rate for Payer: Affinity Medicaid/CHP/HARP	$63,615.22
Rate for Payer: Amida Care Medicaid	$63,615.22
Rate for Payer: EmblemHealth Essential Plan 1&2	$143,134.24
Rate for Payer: EmblemHealth Essential Plan 3&4	$63,615.22
Rate for Payer: Fidelis CHP/HARP/Medicaid	$63,615.22
Rate for Payer: Fidelis Qualified Health Plan	$76,338.26
Rate for Payer: Hamaspik Choice Inc Medicaid	$63,615.22
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$63,615.22
Rate for Payer: Healthfirst Commercial	$121,158.00
Rate for Payer: Healthfirst Essential Plan	$143,134.24
Rate for Payer: Healthfirst QHP	$66,772.00
Rate for Payer: SOMOS CHP/HARP/Medicaid	$63,615.22
Rate for Payer: SOMOS Essential	$143,134.24
Rate for Payer: United Healthcare Essential Plan 1&2	$143,134.24
Rate for Payer: United Healthcare Essential Plan 3&4	$143,134.24
Rate for Payer: United Healthcare Medicaid	$63,615.22
Rate for Payer: Wellcare CHP/FHP/Medicaid	$63,615.22

Tendon, muscle & other soft tissue procedures

Facility

$77,881.25

Service Code	APR-DRG 3173
Min. Negotiated Rate	$26,951.00
Max. Negotiated Rate	$77,881.25
Rate for Payer: Affinity Essential Plan 1&2	$77,881.25
Rate for Payer: Affinity Essential Plan 3&4	$77,881.25
Rate for Payer: Affinity Medicaid/CHP/HARP	$34,613.89
Rate for Payer: Amida Care Medicaid	$34,613.89
Rate for Payer: EmblemHealth Essential Plan 1&2	$77,881.25
Rate for Payer: EmblemHealth Essential Plan 3&4	$34,613.89
Rate for Payer: Fidelis CHP/HARP/Medicaid	$34,613.89
Rate for Payer: Fidelis Qualified Health Plan	$41,536.67
Rate for Payer: Hamaspik Choice Inc Medicaid	$34,613.89
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$34,613.89
Rate for Payer: Healthfirst Commercial	$46,551.00
Rate for Payer: Healthfirst Essential Plan	$77,881.25
Rate for Payer: Healthfirst QHP	$26,951.00
Rate for Payer: SOMOS CHP/HARP/Medicaid	$34,613.89
Rate for Payer: SOMOS Essential	$77,881.25
Rate for Payer: United Healthcare Essential Plan 1&2	$77,881.25
Rate for Payer: United Healthcare Essential Plan 3&4	$77,881.25
Rate for Payer: United Healthcare Medicaid	$34,613.89
Rate for Payer: Wellcare CHP/FHP/Medicaid	$34,613.89

TENECTEPLASE 50 MG/10 ML IV (WET SOLR VIAL)

Facility

$9.00

Service Code	HCPCS J3101
Hospital Charge Code	5024212047
Hospital Revenue Code	258
Min. Negotiated Rate	$4.50
Max. Negotiated Rate	$4.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$4.50

TENECTEPLASE 50 MG/10 ML IV (WET SOLR VIAL)

Facility

$8.00

Service Code	HCPCS J3101
Hospital Charge Code	5024217601
Hospital Revenue Code	258
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$4.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$4.00

TENECTEPLASE 50 MG/10 ML IV (WET SOLR VIAL)

Facility

$8.00

Service Code	HCPCS J3101
Hospital Charge Code	5024217601
Hospital Revenue Code	258
Min. Negotiated Rate	$4.40
Max. Negotiated Rate	$175.66
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$4.40
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$172.22
Rate for Payer: Aetna Government	$172.22
Rate for Payer: Affinity Essential Plan 1&2	$120.55
Rate for Payer: Affinity Essential Plan 3&4	$120.55
Rate for Payer: Affinity Medicaid/CHP/HARP	$120.55
Rate for Payer: Brighton Health Commercial	$6.00
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$172.22
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$6.40
Rate for Payer: Cigna LocalPlus Benefit Plan	$5.44
Rate for Payer: Elderplan Medicare Advantage	$172.22
Rate for Payer: EmblemHealth Commercial	$172.22
Rate for Payer: Fidelis CHP/HARP/Medicaid	$155.00
Rate for Payer: Fidelis Essential Plan Aliesa	$146.39
Rate for Payer: Fidelis Essential Plan QHP	$153.28
Rate for Payer: Fidelis Medicare Advantage	$172.22
Rate for Payer: Fidelis Qualified Health Plan	$153.28
Rate for Payer: Group Health Inc Commercial	$172.22
Rate for Payer: Group Health Inc Medicare	$172.22
Rate for Payer: Hamaspik Choice Inc Medicaid	$172.22
Rate for Payer: Hamaspik Choice Inc Medicare	$172.22
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$172.22
Rate for Payer: Healthfirst Medicare Advantage	$146.39
Rate for Payer: Healthfirst QHP	$172.22
Rate for Payer: Humana Medicare	$175.66
Rate for Payer: Senior Whole Health Medicare Advantage	$172.22
Rate for Payer: United Healthcare Medicare Advantage	$172.22
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$5.20
Rate for Payer: Wellcare CHP/FHP/Medicaid	$163.61
Rate for Payer: Wellcare Medicare	$163.61

TENECTEPLASE 50 MG/10 ML IV (WET SOLR VIAL)

Facility

$9.00

Service Code	HCPCS J3101
Hospital Charge Code	5024212047
Hospital Revenue Code	258
Min. Negotiated Rate	$4.95
Max. Negotiated Rate	$175.66
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$4.95
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$172.22
Rate for Payer: Aetna Government	$172.22
Rate for Payer: Affinity Essential Plan 1&2	$120.55
Rate for Payer: Affinity Essential Plan 3&4	$120.55
Rate for Payer: Affinity Medicaid/CHP/HARP	$120.55
Rate for Payer: Brighton Health Commercial	$6.75
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$172.22
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$7.20
Rate for Payer: Cigna LocalPlus Benefit Plan	$6.12
Rate for Payer: Elderplan Medicare Advantage	$172.22
Rate for Payer: EmblemHealth Commercial	$172.22
Rate for Payer: Fidelis CHP/HARP/Medicaid	$155.00
Rate for Payer: Fidelis Essential Plan Aliesa	$146.39
Rate for Payer: Fidelis Essential Plan QHP	$153.28
Rate for Payer: Fidelis Medicare Advantage	$172.22
Rate for Payer: Fidelis Qualified Health Plan	$153.28
Rate for Payer: Group Health Inc Commercial	$172.22
Rate for Payer: Group Health Inc Medicare	$172.22
Rate for Payer: Hamaspik Choice Inc Medicaid	$172.22
Rate for Payer: Hamaspik Choice Inc Medicare	$172.22
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$172.22
Rate for Payer: Healthfirst Medicare Advantage	$146.39
Rate for Payer: Healthfirst QHP	$172.22
Rate for Payer: Humana Medicare	$175.66
Rate for Payer: Senior Whole Health Medicare Advantage	$172.22
Rate for Payer: United Healthcare Medicare Advantage	$172.22
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$5.85
Rate for Payer: Wellcare CHP/FHP/Medicaid	$163.61
Rate for Payer: Wellcare Medicare	$163.61

TENECTEPLASE 50 MG IV KIT

Facility

$8.00

Service Code	HCPCS J3101
Hospital Charge Code	5024217601
Hospital Revenue Code	258
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$4.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$4.00

TENECTEPLASE 50 MG IV KIT

Facility

$9.00

Service Code	HCPCS J3101
Hospital Charge Code	5024212047
Hospital Revenue Code	258
Min. Negotiated Rate	$4.95
Max. Negotiated Rate	$175.66
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$4.95
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$172.22
Rate for Payer: Aetna Government	$172.22
Rate for Payer: Affinity Essential Plan 1&2	$120.55
Rate for Payer: Affinity Essential Plan 3&4	$120.55
Rate for Payer: Affinity Medicaid/CHP/HARP	$120.55
Rate for Payer: Brighton Health Commercial	$6.75
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$172.22
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$7.20
Rate for Payer: Cigna LocalPlus Benefit Plan	$6.12
Rate for Payer: Elderplan Medicare Advantage	$172.22
Rate for Payer: EmblemHealth Commercial	$172.22
Rate for Payer: Fidelis CHP/HARP/Medicaid	$155.00
Rate for Payer: Fidelis Essential Plan Aliesa	$146.39
Rate for Payer: Fidelis Essential Plan QHP	$153.28
Rate for Payer: Fidelis Medicare Advantage	$172.22
Rate for Payer: Fidelis Qualified Health Plan	$153.28
Rate for Payer: Group Health Inc Commercial	$172.22
Rate for Payer: Group Health Inc Medicare	$172.22
Rate for Payer: Hamaspik Choice Inc Medicaid	$172.22
Rate for Payer: Hamaspik Choice Inc Medicare	$172.22
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$172.22
Rate for Payer: Healthfirst Medicare Advantage	$146.39
Rate for Payer: Healthfirst QHP	$172.22
Rate for Payer: Humana Medicare	$175.66
Rate for Payer: Senior Whole Health Medicare Advantage	$172.22
Rate for Payer: United Healthcare Medicare Advantage	$172.22
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$5.85
Rate for Payer: Wellcare CHP/FHP/Medicaid	$163.61
Rate for Payer: Wellcare Medicare	$163.61

TENECTEPLASE 50 MG IV KIT

Facility

$9.00

Service Code	HCPCS J3101
Hospital Charge Code	5024212047
Hospital Revenue Code	258
Min. Negotiated Rate	$4.50
Max. Negotiated Rate	$4.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$4.50

Know your out-of-pocket cost for care.

All Charges