St. Barnabas Hospital

All Charges

Charge

Type

Price

TENOFOVIR ALAFENAMIDE 25MG

Facility OP

$38.75

Hospital Charge Code	41640358
Hospital Revenue Code	250
Min. Negotiated Rate	$13.56
Max. Negotiated Rate	$31.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$21.31
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$19.38
Rate for Payer: Aetna Government	$19.38
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$31.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$26.35
Rate for Payer: Group Health Inc Commercial	$19.38
Rate for Payer: Group Health Inc Medicare	$13.56
Rate for Payer: Hamaspik Choice Inc Medicaid	$19.38
Rate for Payer: Hamaspik Choice Inc Medicare	$19.38
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$25.19

TENOFOVIR ALAFENAMIDE 25MG

Facility OP

$38.75

Hospital Charge Code	41650358
Hospital Revenue Code	250
Min. Negotiated Rate	$13.56
Max. Negotiated Rate	$31.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$21.31
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$19.38
Rate for Payer: Aetna Government	$19.38
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$31.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$26.35
Rate for Payer: Group Health Inc Commercial	$19.38
Rate for Payer: Group Health Inc Medicare	$13.56
Rate for Payer: Hamaspik Choice Inc Medicaid	$19.38
Rate for Payer: Hamaspik Choice Inc Medicare	$19.38
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$25.19

TENOFOVIR EMTRICIT 300/200MG

Facility OP

$76.49

Hospital Charge Code	41653747
Hospital Revenue Code	250
Min. Negotiated Rate	$26.77
Max. Negotiated Rate	$61.19
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$42.07
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$38.24
Rate for Payer: Aetna Government	$38.24
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$61.19
Rate for Payer: Cigna LocalPlus Benefit Plan	$52.01
Rate for Payer: Group Health Inc Commercial	$38.24
Rate for Payer: Group Health Inc Medicare	$26.77
Rate for Payer: Hamaspik Choice Inc Medicaid	$38.24
Rate for Payer: Hamaspik Choice Inc Medicare	$38.24
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$49.72

TENOFOVIR-EMTRICITABINE 300 MG-200 MG TA

Facility OP

$76.49

Hospital Charge Code	41643747
Hospital Revenue Code	250
Min. Negotiated Rate	$26.77
Max. Negotiated Rate	$61.19
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$42.07
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$38.24
Rate for Payer: Aetna Government	$38.24
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$61.19
Rate for Payer: Cigna LocalPlus Benefit Plan	$52.01
Rate for Payer: Group Health Inc Commercial	$38.24
Rate for Payer: Group Health Inc Medicare	$26.77
Rate for Payer: Hamaspik Choice Inc Medicaid	$38.24
Rate for Payer: Hamaspik Choice Inc Medicare	$38.24
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$49.72

Tenolysis, flexor tendon; palm AND finger, each tendon

Facility OP

$3,743.15

Service Code	CPT 26442
Hospital Revenue Code	360
Min. Negotiated Rate	$1,123.87
Max. Negotiated Rate	$3,743.15
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: 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 CHP/HARP/Medicaid	$1,123.87
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 CHP/FHP/Medicaid	$1,248.74
Rate for Payer: Healthfirst Medicare Advantage	$3,181.68
Rate for Payer: Healthfirst QHP	$3,743.15
Rate for Payer: Senior Whole Health 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

Tenolysis, flexor tendon; palm OR finger, each tendon

Facility OP

$2,915.00

Service Code	CPT 26440
Hospital Revenue Code	360
Min. Negotiated Rate	$740.95
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: 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 CHP/HARP/Medicaid	$740.95
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 CHP/FHP/Medicaid	$823.28
Rate for Payer: Healthfirst Medicare Advantage	$1,579.82
Rate for Payer: Healthfirst QHP	$1,858.61
Rate for Payer: Senior Whole Health 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

TENOTOMY

Facility OP

$8,291.05

Service Code	HCPCS 27606
Hospital Charge Code	40082865
Hospital Revenue Code	360
Min. Negotiated Rate	$301.27
Max. Negotiated Rate	$4,145.52
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,412.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3,743.15
Rate for Payer: Aetna Government	$3,743.15
Rate for Payer: Cash Price	$3,743.15
Rate for Payer: Cash Price	$3,743.15
Rate for Payer: Cash Price	$3,743.15
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 CHP/HARP/Medicaid	$301.27
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 Medicaid	$4,145.52
Rate for Payer: Hamaspik Choice Inc Medicare	$3,743.15
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$334.74
Rate for Payer: Healthfirst Medicare Advantage	$3,181.68
Rate for Payer: Healthfirst QHP	$3,743.15
Rate for Payer: Senior Whole Health 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

TENSILON TEST

Facility OP

$4,105.13

Service Code	HCPCS 95857
Hospital Charge Code	30301225
Hospital Revenue Code	510
Min. Negotiated Rate	$29.86
Max. Negotiated Rate	$2,257.82
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2,257.82
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$362.98
Rate for Payer: Aetna Government	$362.98
Rate for Payer: Brighton Health Commercial	$233.00
Rate for Payer: Cash Price	$362.98
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	$204.58
Rate for Payer: Cigna LocalPlus Benefit Plan	$173.89
Rate for Payer: Elderplan Medicare Advantage	$362.98
Rate for Payer: Fidelis CHP/HARP/Medicaid	$29.86
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	$250.00
Rate for Payer: Group Health Inc Medicare	$250.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,052.56
Rate for Payer: Hamaspik Choice Inc Medicare	$362.98
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$33.18
Rate for Payer: Healthfirst Medicare Advantage	$308.53
Rate for Payer: Healthfirst QHP	$362.98
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$362.98
Rate for Payer: Senior Whole Health 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

TENSILON TEST

Facility OP

$766.58

Service Code	HCPCS 95857
Hospital Charge Code	30301270
Hospital Revenue Code	920
Min. Negotiated Rate	$29.86
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: 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 CHP/HARP/Medicaid	$29.86
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 CHP/FHP/Medicaid	$33.18
Rate for Payer: Healthfirst Medicare Advantage	$308.53
Rate for Payer: Healthfirst QHP	$362.98
Rate for Payer: Senior Whole Health 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

TERBINAFINE 250 MG TAB

Facility OP

$0.30

Hospital Charge Code	41642649
Hospital Revenue Code	250
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$0.24
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.17
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.15
Rate for Payer: Aetna Government	$0.15
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.24
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.20
Rate for Payer: Group Health Inc Commercial	$0.15
Rate for Payer: Group Health Inc Medicare	$0.11
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.15
Rate for Payer: Hamaspik Choice Inc Medicare	$0.15
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.20

TERBINAFINE 250 MG TAB

Facility OP

$0.30

Hospital Charge Code	41652649
Hospital Revenue Code	250
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$0.24
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.17
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.15
Rate for Payer: Aetna Government	$0.15
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.24
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.20
Rate for Payer: Group Health Inc Commercial	$0.15
Rate for Payer: Group Health Inc Medicare	$0.11
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.15
Rate for Payer: Hamaspik Choice Inc Medicare	$0.15
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.20

TERBUTALINE 1 MG/ML INJ

Facility OP

$18.38

Service Code	HCPCS J3105
Hospital Charge Code	41643723
Hospital Revenue Code	636
Min. Negotiated Rate	$2.06
Max. Negotiated Rate	$11.95
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$10.11
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2.53
Rate for Payer: Aetna Government	$2.53
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$9.19
Rate for Payer: Cigna LocalPlus Benefit Plan	$10.57
Rate for Payer: Fidelis CHP/HARP/Medicaid	$2.06
Rate for Payer: Group Health Inc Commercial	$9.19
Rate for Payer: Group Health Inc Medicare	$6.43
Rate for Payer: Hamaspik Choice Inc Medicaid	$9.19
Rate for Payer: Hamaspik Choice Inc Medicare	$9.19
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$2.29
Rate for Payer: SOMOS CHP/HARP/Medicaid	$6.45
Rate for Payer: SOMOS Essential	$6.45
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$11.95

TERBUTALINE 1 MG/ML INJ

Facility OP

$18.38

Service Code	HCPCS J3105
Hospital Charge Code	41653723
Hospital Revenue Code	636
Min. Negotiated Rate	$2.06
Max. Negotiated Rate	$11.95
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$10.11
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2.53
Rate for Payer: Aetna Government	$2.53
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$9.19
Rate for Payer: Cigna LocalPlus Benefit Plan	$10.57
Rate for Payer: Fidelis CHP/HARP/Medicaid	$2.06
Rate for Payer: Group Health Inc Commercial	$9.19
Rate for Payer: Group Health Inc Medicare	$6.43
Rate for Payer: Hamaspik Choice Inc Medicaid	$9.19
Rate for Payer: Hamaspik Choice Inc Medicare	$9.19
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$2.29
Rate for Payer: SOMOS CHP/HARP/Medicaid	$6.45
Rate for Payer: SOMOS Essential	$6.45
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$11.95

TERBUTALINE 1 MG/ML INJ

Facility IP

$18.38

Service Code	HCPCS J3105
Hospital Charge Code	41643723
Hospital Revenue Code	636
Min. Negotiated Rate	$9.19
Max. Negotiated Rate	$9.19
Rate for Payer: Hamaspik Choice Inc Medicaid	$9.19
Rate for Payer: Hamaspik Choice Inc Medicare	$9.19

TERBUTALINE 1 MG/ML INJ

Facility IP

$18.38

Service Code	HCPCS J3105
Hospital Charge Code	41653723
Hospital Revenue Code	636
Min. Negotiated Rate	$9.19
Max. Negotiated Rate	$9.19
Rate for Payer: Hamaspik Choice Inc Medicaid	$9.19
Rate for Payer: Hamaspik Choice Inc Medicare	$9.19

TERBUTALINE 2.5 MG TAB

Facility OP

$0.45

Hospital Charge Code	41644091
Hospital Revenue Code	250
Min. Negotiated Rate	$0.16
Max. Negotiated Rate	$0.36
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.25
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.23
Rate for Payer: Aetna Government	$0.23
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.36
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.31
Rate for Payer: Group Health Inc Commercial	$0.23
Rate for Payer: Group Health Inc Medicare	$0.16
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.23
Rate for Payer: Hamaspik Choice Inc Medicare	$0.23
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.29

TERBUTALINE 2.5 MG TAB

Facility OP

$0.45

Hospital Charge Code	41654091
Hospital Revenue Code	250
Min. Negotiated Rate	$0.16
Max. Negotiated Rate	$0.36
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.25
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.23
Rate for Payer: Aetna Government	$0.23
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.36
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.31
Rate for Payer: Group Health Inc Commercial	$0.23
Rate for Payer: Group Health Inc Medicare	$0.16
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.23
Rate for Payer: Hamaspik Choice Inc Medicare	$0.23
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.29

TERUMO 6FR DESTIION SLENDER SHEAT

Facility OP

$887.50

Hospital Charge Code	66520511
Hospital Revenue Code	270
Min. Negotiated Rate	$310.62
Max. Negotiated Rate	$710.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$488.12
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$443.75
Rate for Payer: Aetna Government	$443.75
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$710.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$603.50
Rate for Payer: Group Health Inc Commercial	$443.75
Rate for Payer: Group Health Inc Medicare	$310.62
Rate for Payer: Hamaspik Choice Inc Medicaid	$443.75
Rate for Payer: Hamaspik Choice Inc Medicare	$443.75

TERUMO FINECROSS MICROCATHETER

Facility OP

$850.00

Hospital Charge Code	66572916
Hospital Revenue Code	272
Min. Negotiated Rate	$297.50
Max. Negotiated Rate	$680.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$467.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$425.00
Rate for Payer: Aetna Government	$425.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$680.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$578.00
Rate for Payer: Group Health Inc Commercial	$425.00
Rate for Payer: Group Health Inc Medicare	$297.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$425.00
Rate for Payer: Hamaspik Choice Inc Medicare	$425.00

TERUMO FR.11 PINN SHEATH

Facility OP

$194.00

Hospital Charge Code	40208132
Hospital Revenue Code	270
Min. Negotiated Rate	$67.90
Max. Negotiated Rate	$155.20
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$106.70
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$97.00
Rate for Payer: Aetna Government	$97.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$155.20
Rate for Payer: Cigna LocalPlus Benefit Plan	$131.92
Rate for Payer: Group Health Inc Commercial	$97.00
Rate for Payer: Group Health Inc Medicare	$67.90
Rate for Payer: Hamaspik Choice Inc Medicaid	$97.00
Rate for Payer: Hamaspik Choice Inc Medicare	$97.00

TERUMO GLIDEWIRE 0.035 X 260CM

Facility OP

$625.00

Service Code	HCPCS C1769
Hospital Charge Code	66520510
Hospital Revenue Code	278
Min. Negotiated Rate	$4.08
Max. Negotiated Rate	$656.25
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$343.75
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$4.08
Rate for Payer: Aetna Government	$4.08
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$312.50
Rate for Payer: Cigna LocalPlus Benefit Plan	$359.38
Rate for Payer: Fidelis Medicare Advantage	$656.25
Rate for Payer: Group Health Inc Commercial	$312.50
Rate for Payer: Group Health Inc Medicare	$218.75
Rate for Payer: Hamaspik Choice Inc Medicaid	$312.50
Rate for Payer: Hamaspik Choice Inc Medicare	$312.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$406.25

TERUMO GLIDEWIRE 0.035 X 260CM

Facility IP

$625.00

Service Code	HCPCS C1769
Hospital Charge Code	66520510
Hospital Revenue Code	278
Min. Negotiated Rate	$312.50
Max. Negotiated Rate	$312.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$312.50
Rate for Payer: Hamaspik Choice Inc Medicare	$312.50

TERUMO GLIDEWIRE 150CM ANGLED

Facility OP

$61.52

Service Code	HCPCS C1713
Hospital Charge Code	40206280
Hospital Revenue Code	278
Min. Negotiated Rate	$21.53
Max. Negotiated Rate	$134.20
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$33.84
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$30.76
Rate for Payer: Cigna LocalPlus Benefit Plan	$35.37
Rate for Payer: Fidelis Medicare Advantage	$64.60
Rate for Payer: Group Health Inc Commercial	$30.76
Rate for Payer: Group Health Inc Medicare	$21.53
Rate for Payer: Hamaspik Choice Inc Medicaid	$30.76
Rate for Payer: Hamaspik Choice Inc Medicare	$30.76
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$39.99

TERUMO GLIDEWIRE 150CM ANGLED

Facility IP

$61.52

Service Code	HCPCS C1713
Hospital Charge Code	40206280
Hospital Revenue Code	278
Min. Negotiated Rate	$30.76
Max. Negotiated Rate	$30.76
Rate for Payer: Hamaspik Choice Inc Medicaid	$30.76
Rate for Payer: Hamaspik Choice Inc Medicare	$30.76

TERUMO GUIDE WIRE .035X150CM

Facility OP

$61.40

Service Code	HCPCS C1769
Hospital Charge Code	40205598
Hospital Revenue Code	278
Min. Negotiated Rate	$4.08
Max. Negotiated Rate	$64.47
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$33.77
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$4.08
Rate for Payer: Aetna Government	$4.08
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$30.70
Rate for Payer: Cigna LocalPlus Benefit Plan	$35.30
Rate for Payer: Fidelis Medicare Advantage	$64.47
Rate for Payer: Group Health Inc Commercial	$30.70
Rate for Payer: Group Health Inc Medicare	$21.49
Rate for Payer: Hamaspik Choice Inc Medicaid	$30.70
Rate for Payer: Hamaspik Choice Inc Medicare	$30.70
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$39.91

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