|
TETANUS IMMUNE GLOBULIN 250 UNITS INJ
|
Facility
OP
|
$650.12
|
|
|
Service Code
|
HCPCS J1670
|
| Hospital Charge Code |
41644396
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$325.06 |
| Max. Negotiated Rate |
$613.51 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$357.57
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$578.61
|
| Rate for Payer: Aetna Government |
$578.61
|
| Rate for Payer: Cash Price |
$578.61
|
| Rate for Payer: Cash Price |
$578.61
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$578.61
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$325.06
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$373.82
|
| Rate for Payer: Elderplan Medicare Advantage |
$578.61
|
| Rate for Payer: EmblemHealth Commercial |
$578.61
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$578.61
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$578.61
|
| Rate for Payer: Fidelis Essential Plan QHP |
$607.54
|
| Rate for Payer: Fidelis Medicare Advantage |
$578.61
|
| Rate for Payer: Fidelis Qualified Health Plan |
$607.54
|
| Rate for Payer: Group Health Inc Commercial |
$578.61
|
| Rate for Payer: Group Health Inc Medicare |
$578.61
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$325.06
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$325.06
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$540.99
|
| Rate for Payer: Healthfirst Medicare Advantage |
$491.82
|
| Rate for Payer: Healthfirst QHP |
$578.61
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$578.61
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$613.51
|
| Rate for Payer: SOMOS Essential |
$613.51
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$422.58
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$462.89
|
| Rate for Payer: Wellcare Medicare |
$549.68
|
|
|
TETANUS TEXOID ADSORBED
|
Facility
OP
|
$47.18
|
|
| Hospital Charge Code |
30100174
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.51 |
| Max. Negotiated Rate |
$37.74 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$25.95
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$23.59
|
| Rate for Payer: Aetna Government |
$23.59
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$37.74
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$32.08
|
| Rate for Payer: Group Health Inc Commercial |
$23.59
|
| Rate for Payer: Group Health Inc Medicare |
$16.51
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$23.59
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$23.59
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$30.67
|
|
|
TETANUS TOXOID 5 UNITS/0.5 ML INJ
|
Facility
OP
|
$54.00
|
|
| Hospital Charge Code |
41654493
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.90 |
| Max. Negotiated Rate |
$43.20 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$29.70
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$27.00
|
| Rate for Payer: Aetna Government |
$27.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$43.20
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$36.72
|
| Rate for Payer: Group Health Inc Commercial |
$27.00
|
| Rate for Payer: Group Health Inc Medicare |
$18.90
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$27.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$27.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$35.10
|
|
|
TETANUS TOXOID 5 UNITS/0.5 ML INJ
|
Facility
OP
|
$54.00
|
|
| Hospital Charge Code |
41644493
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.90 |
| Max. Negotiated Rate |
$43.20 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$29.70
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$27.00
|
| Rate for Payer: Aetna Government |
$27.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$43.20
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$36.72
|
| Rate for Payer: Group Health Inc Commercial |
$27.00
|
| Rate for Payer: Group Health Inc Medicare |
$18.90
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$27.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$27.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$35.10
|
|
|
TETNUS IMMUNE GLOBIN
|
Facility
OP
|
$107.64
|
|
|
Service Code
|
HCPCS 90389
|
| Hospital Charge Code |
30105136
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.67 |
| Max. Negotiated Rate |
$595.90 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$59.20
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$595.90
|
| Rate for Payer: Aetna Government |
$595.90
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$86.11
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$73.20
|
| Rate for Payer: Group Health Inc Commercial |
$53.82
|
| Rate for Payer: Group Health Inc Medicare |
$37.67
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$53.82
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$53.82
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$69.97
|
|
|
TETRACAINE 0.5% OPHTHALMIC SOLN 15 ML
|
Facility
OP
|
$15.00
|
|
| Hospital Charge Code |
41642229
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.25 |
| Max. Negotiated Rate |
$12.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$8.25
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$7.50
|
| Rate for Payer: Aetna Government |
$7.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$12.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$10.20
|
| Rate for Payer: Group Health Inc Commercial |
$7.50
|
| Rate for Payer: Group Health Inc Medicare |
$5.25
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$7.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$7.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$9.75
|
|
|
TETRACAINE 0.5% OPHTHALMIC SOLN 15 ML
|
Facility
OP
|
$15.00
|
|
| Hospital Charge Code |
41652229
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.25 |
| Max. Negotiated Rate |
$12.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$8.25
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$7.50
|
| Rate for Payer: Aetna Government |
$7.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$12.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$10.20
|
| Rate for Payer: Group Health Inc Commercial |
$7.50
|
| Rate for Payer: Group Health Inc Medicare |
$5.25
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$7.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$7.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$9.75
|
|
|
TETRACAINE 0.5% OPHTHALMIC SOLN 2 ML
|
Facility
OP
|
$10.83
|
|
| Hospital Charge Code |
41643638
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.79 |
| Max. Negotiated Rate |
$8.66 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$5.96
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$5.42
|
| Rate for Payer: Aetna Government |
$5.42
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$8.66
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$7.36
|
| Rate for Payer: Group Health Inc Commercial |
$5.42
|
| Rate for Payer: Group Health Inc Medicare |
$3.79
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$5.42
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$5.42
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$7.04
|
|
|
TETRACAINE 0.5% OPHTHALMIC SOLN 2 ML
|
Facility
OP
|
$10.83
|
|
| Hospital Charge Code |
41653638
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.79 |
| Max. Negotiated Rate |
$8.66 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$5.96
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$5.42
|
| Rate for Payer: Aetna Government |
$5.42
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$8.66
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$7.36
|
| Rate for Payer: Group Health Inc Commercial |
$5.42
|
| Rate for Payer: Group Health Inc Medicare |
$3.79
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$5.42
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$5.42
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$7.04
|
|
|
TETRACAINE 1% INJ
|
Facility
OP
|
$9.00
|
|
| Hospital Charge Code |
41643936
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.15 |
| Max. Negotiated Rate |
$7.20 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$4.95
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$4.50
|
| Rate for Payer: Aetna Government |
$4.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$7.20
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$6.12
|
| Rate for Payer: Group Health Inc Commercial |
$4.50
|
| Rate for Payer: Group Health Inc Medicare |
$3.15
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$5.85
|
|
|
TETRACAINE 1% INJ
|
Facility
OP
|
$9.00
|
|
| Hospital Charge Code |
41653936
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.15 |
| Max. Negotiated Rate |
$7.20 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$4.95
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$4.50
|
| Rate for Payer: Aetna Government |
$4.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$7.20
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$6.12
|
| Rate for Payer: Group Health Inc Commercial |
$4.50
|
| Rate for Payer: Group Health Inc Medicare |
$3.15
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$5.85
|
|
|
TETRACAINE 2% TOPICAL SOLUTION
|
Facility
OP
|
$84.00
|
|
| Hospital Charge Code |
41644206
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$29.40 |
| Max. Negotiated Rate |
$67.20 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$46.20
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$42.00
|
| Rate for Payer: Aetna Government |
$42.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$67.20
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$57.12
|
| Rate for Payer: Group Health Inc Commercial |
$42.00
|
| Rate for Payer: Group Health Inc Medicare |
$29.40
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$42.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$42.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$54.60
|
|
|
TETRACAINE 2% TOPICAL SOLUTION
|
Facility
OP
|
$84.00
|
|
| Hospital Charge Code |
41654206
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$29.40 |
| Max. Negotiated Rate |
$67.20 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$46.20
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$42.00
|
| Rate for Payer: Aetna Government |
$42.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$67.20
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$57.12
|
| Rate for Payer: Group Health Inc Commercial |
$42.00
|
| Rate for Payer: Group Health Inc Medicare |
$29.40
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$42.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$42.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$54.60
|
|
|
TETRACAINE HCL 0.5% OPHTH SOLN 4M
|
Facility
OP
|
$10.45
|
|
| Hospital Charge Code |
41656651
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.66 |
| Max. Negotiated Rate |
$8.36 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$5.75
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$5.22
|
| Rate for Payer: Aetna Government |
$5.22
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$8.36
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$7.11
|
| Rate for Payer: Group Health Inc Commercial |
$5.22
|
| Rate for Payer: Group Health Inc Medicare |
$3.66
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$5.22
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$5.22
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$6.79
|
|
|
TETRACAINE HCL 0.5% OPTH SOLN 4ML
|
Facility
OP
|
$10.45
|
|
| Hospital Charge Code |
41646651
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.66 |
| Max. Negotiated Rate |
$8.36 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$5.75
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$5.22
|
| Rate for Payer: Aetna Government |
$5.22
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$8.36
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$7.11
|
| Rate for Payer: Group Health Inc Commercial |
$5.22
|
| Rate for Payer: Group Health Inc Medicare |
$3.66
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$5.22
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$5.22
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$6.79
|
|
|
TETRACYCLINE 250 MG CAP
|
Facility
OP
|
$1.00
|
|
| Hospital Charge Code |
41640699
|
|
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: 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
|
|
|
TETRACYCLINE 250 MG CAP
|
Facility
OP
|
$1.00
|
|
| Hospital Charge Code |
41650699
|
|
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: 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
|
|
|
TETRACYCLINE 500 MG CAP
|
Facility
OP
|
$1.00
|
|
| Hospital Charge Code |
41650822
|
|
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: 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
|
|
|
TETRACYCLINE 500 MG CAP
|
Facility
OP
|
$1.00
|
|
| Hospital Charge Code |
41640822
|
|
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: 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
|
|
|
TETRAHYDROZOLINE 0.05% OPHTHALMIC SOLN
|
Facility
OP
|
$3.00
|
|
| Hospital Charge Code |
41640728
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.05 |
| Max. Negotiated Rate |
$2.40 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.65
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.50
|
| Rate for Payer: Aetna Government |
$1.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2.40
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2.04
|
| Rate for Payer: Group Health Inc Commercial |
$1.50
|
| Rate for Payer: Group Health Inc Medicare |
$1.05
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.95
|
|
|
TETRAHYDROZOLINE 0.05% OPHTHALMIC SOLN
|
Facility
OP
|
$3.00
|
|
| Hospital Charge Code |
41650728
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.05 |
| Max. Negotiated Rate |
$2.40 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.65
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.50
|
| Rate for Payer: Aetna Government |
$1.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2.40
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2.04
|
| Rate for Payer: Group Health Inc Commercial |
$1.50
|
| Rate for Payer: Group Health Inc Medicare |
$1.05
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.95
|
|
|
TEXAS CATHETER
|
Facility
OP
|
$17.01
|
|
| Hospital Charge Code |
40206004
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$5.95 |
| Max. Negotiated Rate |
$13.61 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$9.36
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$8.50
|
| Rate for Payer: Aetna Government |
$8.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$13.61
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$11.57
|
| Rate for Payer: Group Health Inc Commercial |
$8.50
|
| Rate for Payer: Group Health Inc Medicare |
$5.95
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$8.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$8.50
|
|
|
TEZEPELUMAB-EKKO 210MG
|
Facility
IP
|
$43.25
|
|
|
Service Code
|
HCPCS J2356
|
| Hospital Charge Code |
41650386
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.62 |
| Max. Negotiated Rate |
$21.62 |
| Rate for Payer: Cash Price |
$18.59
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$21.62
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$21.62
|
|
|
TEZEPELUMAB-EKKO 210MG
|
Facility
IP
|
$43.25
|
|
|
Service Code
|
HCPCS J2356
|
| Hospital Charge Code |
41640386
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.62 |
| Max. Negotiated Rate |
$21.62 |
| Rate for Payer: Cash Price |
$18.59
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$21.62
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$21.62
|
|
|
TEZEPELUMAB-EKKO 210MG
|
Facility
OP
|
$43.25
|
|
|
Service Code
|
HCPCS J2356
|
| Hospital Charge Code |
41640386
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.87 |
| Max. Negotiated Rate |
$28.11 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$23.79
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$18.59
|
| Rate for Payer: Aetna Government |
$18.59
|
| Rate for Payer: Cash Price |
$18.59
|
| Rate for Payer: Cash Price |
$18.59
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$18.59
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$21.62
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$24.87
|
| Rate for Payer: Elderplan Medicare Advantage |
$18.59
|
| Rate for Payer: EmblemHealth Commercial |
$18.59
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$18.59
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$18.59
|
| Rate for Payer: Fidelis Essential Plan QHP |
$19.52
|
| Rate for Payer: Fidelis Medicare Advantage |
$18.59
|
| Rate for Payer: Fidelis Qualified Health Plan |
$19.52
|
| Rate for Payer: Group Health Inc Commercial |
$18.59
|
| Rate for Payer: Group Health Inc Medicare |
$18.59
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$21.62
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$21.62
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$18.73
|
| Rate for Payer: Healthfirst Medicare Advantage |
$15.80
|
| Rate for Payer: Healthfirst QHP |
$18.59
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$18.59
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$18.87
|
| Rate for Payer: SOMOS Essential |
$18.87
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$28.11
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$14.87
|
| Rate for Payer: Wellcare Medicare |
$17.66
|
|
