|
TI ROD RELINE MAS 5.5X40MM
|
Facility
OP
|
$1,172.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
64905338
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$134.20 |
| Max. Negotiated Rate |
$1,231.12 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$644.88
|
| 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 |
$586.25
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$674.19
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,231.12
|
| Rate for Payer: Group Health Inc Commercial |
$586.25
|
| Rate for Payer: Group Health Inc Medicare |
$410.38
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$586.25
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$586.25
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$762.12
|
|
|
TI ROD RELINE MAS 5.5X40MM
|
Facility
IP
|
$1,172.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
64905338
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$586.25 |
| Max. Negotiated Rate |
$586.25 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$586.25
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$586.25
|
|
|
TI SPLINT LARGE-5 MM WIDTH
|
Facility
OP
|
$900.00
|
|
| Hospital Charge Code |
40209501
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$315.00 |
| Max. Negotiated Rate |
$720.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$495.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$450.00
|
| Rate for Payer: Aetna Government |
$450.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$720.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$612.00
|
| Rate for Payer: Group Health Inc Commercial |
$450.00
|
| Rate for Payer: Group Health Inc Medicare |
$315.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$450.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$450.00
|
|
|
TISSEEL SEALANT FIBRIN 10ML
|
Facility
OP
|
$1,367.78
|
|
| Hospital Charge Code |
64903238
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$478.72 |
| Max. Negotiated Rate |
$1,094.22 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$752.28
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$683.89
|
| Rate for Payer: Aetna Government |
$683.89
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,094.22
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$930.09
|
| Rate for Payer: Group Health Inc Commercial |
$683.89
|
| Rate for Payer: Group Health Inc Medicare |
$478.72
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$683.89
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$683.89
|
|
|
TISSEEL SEALANT FRZ PREFIL 10ML
|
Facility
OP
|
$1,283.75
|
|
| Hospital Charge Code |
64904950
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$449.31 |
| Max. Negotiated Rate |
$1,027.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$706.06
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$641.88
|
| Rate for Payer: Aetna Government |
$641.88
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,027.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$872.95
|
| Rate for Payer: Group Health Inc Commercial |
$641.88
|
| Rate for Payer: Group Health Inc Medicare |
$449.31
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$641.88
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$641.88
|
|
|
TISSUE ALLODRM CTR 9.6X19.3 MED
|
Facility
IP
|
$76.95
|
|
|
Service Code
|
HCPCS Q4116
|
| Hospital Charge Code |
64904592
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$38.48 |
| Max. Negotiated Rate |
$38.48 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$38.48
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$38.48
|
|
|
TISSUE ALLODRM CTR 9.6X19.3 MED
|
Facility
OP
|
$76.95
|
|
|
Service Code
|
HCPCS Q4116
|
| Hospital Charge Code |
64904592
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.47 |
| Max. Negotiated Rate |
$50.02 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$42.32
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$21.47
|
| Rate for Payer: Aetna Government |
$21.47
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$38.48
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$44.25
|
| Rate for Payer: Group Health Inc Commercial |
$38.48
|
| Rate for Payer: Group Health Inc Medicare |
$26.93
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$38.48
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$38.48
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$50.02
|
|
|
TISSUE BIOPSY BAG ITEM BLUE
|
Facility
OP
|
$35.75
|
|
| Hospital Charge Code |
64902716
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$12.51 |
| Max. Negotiated Rate |
$28.60 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$19.66
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$17.88
|
| Rate for Payer: Aetna Government |
$17.88
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$28.60
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$24.31
|
| Rate for Payer: Group Health Inc Commercial |
$17.88
|
| Rate for Payer: Group Health Inc Medicare |
$12.51
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$17.88
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$17.88
|
|
|
TISSUE CONDITIONING, LOWER-PER DE
|
Facility
OP
|
$62.50
|
|
|
Service Code
|
HCPCS D5851
|
| Hospital Charge Code |
42301190
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$21.88 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$34.38
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$38.55
|
| Rate for Payer: Aetna Government |
$38.55
|
| 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: Group Health Inc Commercial |
$31.25
|
| Rate for Payer: Group Health Inc Medicare |
$21.88
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$31.25
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$31.25
|
|
|
TISSUE CONDITIONING, UPPER-PER DE
|
Facility
OP
|
$62.50
|
|
|
Service Code
|
HCPCS D5850
|
| Hospital Charge Code |
42301185
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$21.88 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$34.38
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$38.55
|
| Rate for Payer: Aetna Government |
$38.55
|
| 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: Group Health Inc Commercial |
$31.25
|
| Rate for Payer: Group Health Inc Medicare |
$21.88
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$31.25
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$31.25
|
|
|
TISSUE EXAM FOR FUNGI
|
Facility
OP
|
$10.68
|
|
|
Service Code
|
HCPCS 87220
|
| Hospital Charge Code |
40614334
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$3.42 |
| Max. Negotiated Rate |
$6.79 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$5.87
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$4.27
|
| Rate for Payer: Aetna Government |
$4.27
|
| Rate for Payer: Cash Price |
$4.27
|
| Rate for Payer: Cash Price |
$4.27
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$4.27
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$6.79
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$5.74
|
| Rate for Payer: Elderplan Medicare Advantage |
$4.27
|
| Rate for Payer: EmblemHealth Commercial |
$4.27
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$3.84
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$3.63
|
| Rate for Payer: Fidelis Essential Plan QHP |
$3.80
|
| Rate for Payer: Fidelis Medicare Advantage |
$4.27
|
| Rate for Payer: Fidelis Qualified Health Plan |
$3.80
|
| Rate for Payer: Group Health Inc Commercial |
$4.27
|
| Rate for Payer: Group Health Inc Medicare |
$4.27
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$5.34
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4.27
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$4.27
|
| Rate for Payer: Healthfirst Medicare Advantage |
$4.27
|
| Rate for Payer: Healthfirst QHP |
$4.27
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$4.27
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$4.27
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$3.42
|
| Rate for Payer: Wellcare Medicare |
$3.84
|
|
|
TISSUE EXAM FOR FUNGI
|
Facility
OP
|
$10.68
|
|
|
Service Code
|
HCPCS 87220
|
| Hospital Charge Code |
30305952
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$3.42 |
| Max. Negotiated Rate |
$6.79 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$5.87
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$4.27
|
| Rate for Payer: Aetna Government |
$4.27
|
| Rate for Payer: Cash Price |
$4.27
|
| Rate for Payer: Cash Price |
$4.27
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$4.27
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$6.79
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$5.74
|
| Rate for Payer: Elderplan Medicare Advantage |
$4.27
|
| Rate for Payer: EmblemHealth Commercial |
$4.27
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$3.84
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$3.63
|
| Rate for Payer: Fidelis Essential Plan QHP |
$3.80
|
| Rate for Payer: Fidelis Medicare Advantage |
$4.27
|
| Rate for Payer: Fidelis Qualified Health Plan |
$3.80
|
| Rate for Payer: Group Health Inc Commercial |
$4.27
|
| Rate for Payer: Group Health Inc Medicare |
$4.27
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$5.34
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4.27
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$4.27
|
| Rate for Payer: Healthfirst Medicare Advantage |
$4.27
|
| Rate for Payer: Healthfirst QHP |
$4.27
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$4.27
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$4.27
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$3.42
|
| Rate for Payer: Wellcare Medicare |
$3.84
|
|
|
TISSUE HOMOGENIZATION CULTR
|
Facility
OP
|
$14.70
|
|
|
Service Code
|
HCPCS 87176
|
| Hospital Charge Code |
40614339
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$4.70 |
| Max. Negotiated Rate |
$9.36 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$8.08
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$5.88
|
| Rate for Payer: Aetna Government |
$5.88
|
| Rate for Payer: Cash Price |
$5.88
|
| Rate for Payer: Cash Price |
$5.88
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$5.88
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$9.36
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$7.92
|
| Rate for Payer: Elderplan Medicare Advantage |
$5.88
|
| Rate for Payer: EmblemHealth Commercial |
$5.88
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$5.29
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$5.00
|
| Rate for Payer: Fidelis Essential Plan QHP |
$5.23
|
| Rate for Payer: Fidelis Medicare Advantage |
$5.88
|
| Rate for Payer: Fidelis Qualified Health Plan |
$5.23
|
| Rate for Payer: Group Health Inc Commercial |
$5.88
|
| Rate for Payer: Group Health Inc Medicare |
$5.88
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$7.35
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$5.88
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$5.88
|
| Rate for Payer: Healthfirst Medicare Advantage |
$5.88
|
| Rate for Payer: Healthfirst QHP |
$5.88
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$5.88
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$5.88
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$4.70
|
| Rate for Payer: Wellcare Medicare |
$5.29
|
|
|
TISSUE MATRIX 20X20
|
Facility
IP
|
$21,546.00
|
|
|
Service Code
|
HCPCS Q4100
|
| Hospital Charge Code |
40203055
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10,773.00 |
| Max. Negotiated Rate |
$10,773.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$10,773.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$10,773.00
|
|
|
TISSUE MATRIX 20X20
|
Facility
OP
|
$21,546.00
|
|
|
Service Code
|
HCPCS Q4100
|
| Hospital Charge Code |
40203055
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.74 |
| Max. Negotiated Rate |
$14,004.90 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$11,850.30
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$9.74
|
| Rate for Payer: Aetna Government |
$9.74
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$10,773.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$12,388.95
|
| Rate for Payer: Group Health Inc Commercial |
$10,773.00
|
| Rate for Payer: Group Health Inc Medicare |
$7,541.10
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$10,773.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$10,773.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$14,004.90
|
|
|
TISSUE MATRIX PER SQ CM - 1
|
Facility
OP
|
$23.63
|
|
|
Service Code
|
HCPCS Q4116
|
| Hospital Charge Code |
40203102
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.27 |
| Max. Negotiated Rate |
$21.47 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$13.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$21.47
|
| Rate for Payer: Aetna Government |
$21.47
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$11.82
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$13.59
|
| Rate for Payer: Group Health Inc Commercial |
$11.82
|
| Rate for Payer: Group Health Inc Medicare |
$8.27
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$11.82
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$11.82
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$15.36
|
|
|
TISSUE MATRIX PER SQ CM - 1
|
Facility
IP
|
$23.63
|
|
|
Service Code
|
HCPCS Q4116
|
| Hospital Charge Code |
40203102
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.82 |
| Max. Negotiated Rate |
$11.82 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$11.82
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$11.82
|
|
|
TISSUE MATRIX PER SQ CM - 2
|
Facility
OP
|
$126.60
|
|
|
Service Code
|
HCPCS Q4116
|
| Hospital Charge Code |
40203108
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.47 |
| Max. Negotiated Rate |
$82.29 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$69.63
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$21.47
|
| Rate for Payer: Aetna Government |
$21.47
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$63.30
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$72.80
|
| Rate for Payer: Group Health Inc Commercial |
$63.30
|
| Rate for Payer: Group Health Inc Medicare |
$44.31
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$63.30
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$63.30
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$82.29
|
|
|
TISSUE MATRIX PER SQ CM - 2
|
Facility
IP
|
$126.60
|
|
|
Service Code
|
HCPCS Q4116
|
| Hospital Charge Code |
40203108
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$63.30 |
| Max. Negotiated Rate |
$63.30 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$63.30
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$63.30
|
|
|
TISSUE MEND 4X4
|
Facility
OP
|
$5,000.00
|
|
| Hospital Charge Code |
40209861
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,750.00 |
| Max. Negotiated Rate |
$4,000.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,750.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2,500.00
|
| Rate for Payer: Aetna Government |
$2,500.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$4,000.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$3,400.00
|
| Rate for Payer: Group Health Inc Commercial |
$2,500.00
|
| Rate for Payer: Group Health Inc Medicare |
$1,750.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,500.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2,500.00
|
|
|
TISSUE TRANSGLUTAM AB IGA
|
Facility
OP
|
$28.83
|
|
|
Service Code
|
HCPCS 83516
|
| Hospital Charge Code |
40608384
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$9.22 |
| Max. Negotiated Rate |
$18.34 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$15.86
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$11.53
|
| Rate for Payer: Aetna Government |
$11.53
|
| Rate for Payer: Cash Price |
$11.53
|
| Rate for Payer: Cash Price |
$11.53
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$11.53
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$18.34
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$15.52
|
| Rate for Payer: Elderplan Medicare Advantage |
$11.53
|
| Rate for Payer: EmblemHealth Commercial |
$11.53
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$10.38
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$9.80
|
| Rate for Payer: Fidelis Essential Plan QHP |
$10.26
|
| Rate for Payer: Fidelis Medicare Advantage |
$11.53
|
| Rate for Payer: Fidelis Qualified Health Plan |
$10.26
|
| Rate for Payer: Group Health Inc Commercial |
$11.53
|
| Rate for Payer: Group Health Inc Medicare |
$11.53
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$14.42
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$11.53
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$11.53
|
| Rate for Payer: Healthfirst Medicare Advantage |
$11.53
|
| Rate for Payer: Healthfirst QHP |
$11.53
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$11.53
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$11.53
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$9.22
|
| Rate for Payer: Wellcare Medicare |
$10.38
|
|
|
TISS XPNDR PLMT BRST RCNSTJ
|
Facility
OP
|
$41,958.28
|
|
|
Service Code
|
HCPCS 19357
|
| Hospital Charge Code |
40063228
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,304.96 |
| Max. Negotiated Rate |
$20,979.14 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,880.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$20,378.37
|
| Rate for Payer: Aetna Government |
$20,378.37
|
| Rate for Payer: Cash Price |
$20,378.37
|
| Rate for Payer: Cash Price |
$20,378.37
|
| Rate for Payer: Cash Price |
$20,378.37
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$20,378.37
|
| 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 |
$20,378.37
|
| Rate for Payer: EmblemHealth Commercial |
$1,505.00
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$1,304.96
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$17,321.61
|
| Rate for Payer: Fidelis Essential Plan QHP |
$18,136.75
|
| Rate for Payer: Fidelis Medicare Advantage |
$20,378.37
|
| Rate for Payer: Fidelis Qualified Health Plan |
$18,136.75
|
| Rate for Payer: Group Health Inc Commercial |
$20,378.37
|
| Rate for Payer: Group Health Inc Medicare |
$20,378.37
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$20,979.14
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$20,378.37
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$1,449.96
|
| Rate for Payer: Healthfirst Medicare Advantage |
$17,321.61
|
| Rate for Payer: Healthfirst QHP |
$20,378.37
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$20,378.37
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$20,378.37
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$16,302.70
|
| Rate for Payer: Wellcare Medicare |
$19,359.45
|
|
|
TITAN ASSEMBLY KIT
|
Facility
OP
|
$1,325.00
|
|
| Hospital Charge Code |
64905594
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$463.75 |
| Max. Negotiated Rate |
$1,060.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$728.75
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$662.50
|
| Rate for Payer: Aetna Government |
$662.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,060.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$901.00
|
| Rate for Payer: Group Health Inc Commercial |
$662.50
|
| Rate for Payer: Group Health Inc Medicare |
$463.75
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$662.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$662.50
|
|
|
TITAN CL RESERVOIR ER8075
|
Facility
OP
|
$4,825.00
|
|
|
Service Code
|
HCPCS C1813
|
| Hospital Charge Code |
64903196
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,688.75 |
| Max. Negotiated Rate |
$5,066.25 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,653.75
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3,775.00
|
| Rate for Payer: Aetna Government |
$3,775.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2,412.50
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,774.38
|
| Rate for Payer: Fidelis Medicare Advantage |
$5,066.25
|
| Rate for Payer: Group Health Inc Commercial |
$2,412.50
|
| Rate for Payer: Group Health Inc Medicare |
$1,688.75
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,412.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2,412.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3,136.25
|
|
|
TITAN CL RESERVOIR ER8075
|
Facility
IP
|
$4,825.00
|
|
|
Service Code
|
HCPCS C1813
|
| Hospital Charge Code |
64903196
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,412.50 |
| Max. Negotiated Rate |
$2,412.50 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,412.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2,412.50
|
|
