St. Barnabas Hospital

All Charges

Charge

Type

Price

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 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 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 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 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

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

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