|
TEMPLATE BENDING HOLEX12 F/3.5
|
Facility
|
OP
|
$135.00
|
|
| Hospital Charge Code |
64905568
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$47.25 |
| Max. Negotiated Rate |
$108.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$74.25
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$67.50
|
| Rate for Payer: Aetna Government |
$67.50
|
| Rate for Payer: Brighton Health Commercial |
$101.25
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$108.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$91.80
|
| Rate for Payer: Group Health Inc Commercial |
$67.50
|
| Rate for Payer: Group Health Inc Medicare |
$47.25
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$67.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$67.50
|
|
|
TEMPLATE,ENDOFORM,DERMAL,2X2,FE
|
Facility
|
OP
|
$25.23
|
|
| Hospital Charge Code |
64903676
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$8.83 |
| Max. Negotiated Rate |
$20.18 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$13.88
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$12.62
|
| Rate for Payer: Aetna Government |
$12.62
|
| Rate for Payer: Brighton Health Commercial |
$18.92
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$20.18
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$17.16
|
| Rate for Payer: Group Health Inc Commercial |
$12.62
|
| Rate for Payer: Group Health Inc Medicare |
$8.83
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$12.62
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$12.62
|
|
|
TEMPLATE ORTHO
|
Facility
|
OP
|
$110.33
|
|
| Hospital Charge Code |
64907136
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$38.62 |
| Max. Negotiated Rate |
$88.26 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$60.68
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$55.16
|
| Rate for Payer: Aetna Government |
$55.16
|
| Rate for Payer: Brighton Health Commercial |
$82.75
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$88.26
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$75.02
|
| Rate for Payer: Group Health Inc Commercial |
$55.16
|
| Rate for Payer: Group Health Inc Medicare |
$38.62
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$55.16
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$55.16
|
|
|
TEMPLATE ROD 120MM
|
Facility
|
OP
|
$610.00
|
|
| Hospital Charge Code |
40205527
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$213.50 |
| Max. Negotiated Rate |
$488.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$335.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$305.00
|
| Rate for Payer: Aetna Government |
$305.00
|
| Rate for Payer: Brighton Health Commercial |
$457.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$488.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$414.80
|
| Rate for Payer: Group Health Inc Commercial |
$305.00
|
| Rate for Payer: Group Health Inc Medicare |
$213.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$305.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$305.00
|
|
|
TEMPORARY CONDYLAR PROTHESIS, RT
|
Facility
|
IP
|
$1,724.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
40200738
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$862.00 |
| Max. Negotiated Rate |
$862.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$862.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$862.00
|
|
|
TEMPORARY CONDYLAR PROTHESIS, RT
|
Facility
|
OP
|
$1,724.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
40200738
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$339.17 |
| Max. Negotiated Rate |
$1,810.20 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$948.20
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$339.17
|
| Rate for Payer: Aetna Government |
$339.17
|
| Rate for Payer: Brighton Health Commercial |
$1,034.40
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$862.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$991.30
|
| Rate for Payer: EmblemHealth Commercial |
$862.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,810.20
|
| Rate for Payer: Group Health Inc Commercial |
$862.00
|
| Rate for Payer: Group Health Inc Medicare |
$603.40
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$862.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$862.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,120.60
|
|
|
TEMPORARY PACEMAKER
|
Facility
|
IP
|
$8,393.53
|
|
|
Service Code
|
HCPCS 33210
|
| Hospital Charge Code |
30103283
|
|
Hospital Revenue Code
|
450
|
| Rate for Payer: Cash Price |
$9,824.59
|
|
|
TEMPORARY PACEMAKER
|
Facility
|
OP
|
$8,393.53
|
|
|
Service Code
|
HCPCS 33210
|
| Hospital Charge Code |
30103283
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$165.00 |
| Max. Negotiated Rate |
$9,824.59 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$5,593.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$9,824.59
|
| Rate for Payer: Aetna Government |
$9,824.59
|
| Rate for Payer: Brighton Health Commercial |
$874.00
|
| Rate for Payer: Carelon Behavioral Health CHP/Medicaid |
$9,824.59
|
| Rate for Payer: Carelon Behavioral Health Medicare Advantage |
$9,824.59
|
| Rate for Payer: Cash Price |
$9,824.59
|
| Rate for Payer: Cash Price |
$9,824.59
|
| Rate for Payer: Cash Price |
$9,824.59
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$9,824.59
|
| 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 |
$9,824.59
|
| Rate for Payer: EmblemHealth Commercial |
$525.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$8,350.90
|
| Rate for Payer: Fidelis Essential Plan QHP |
$8,743.89
|
| Rate for Payer: Fidelis Medicare Advantage |
$9,824.59
|
| Rate for Payer: Fidelis Qualified Health Plan |
$8,743.89
|
| Rate for Payer: Group Health Inc Commercial |
$525.00
|
| Rate for Payer: Group Health Inc Medicare |
$525.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4,196.76
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$9,824.59
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$165.00
|
| Rate for Payer: Healthfirst Medicare Advantage |
$225.00
|
| Rate for Payer: Healthfirst QHP |
$9,824.59
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$9,824.59
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$9,824.59
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$9,824.59
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$7,859.67
|
| Rate for Payer: Wellcare Medicare |
$9,333.36
|
|
|
TEMPORARY PACEMAKER
|
Facility
|
IP
|
$23,145.25
|
|
|
Service Code
|
HCPCS 33210
|
| Hospital Charge Code |
40011365
|
|
Hospital Revenue Code
|
360
|
| Rate for Payer: Cash Price |
$9,824.59
|
|
|
TEMPORARY PACEMAKER
|
Facility
|
OP
|
$23,145.25
|
|
|
Service Code
|
HCPCS 33210
|
| Hospital Charge Code |
40011365
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,505.00 |
| Max. Negotiated Rate |
$17,358.94 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$5,593.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$9,824.59
|
| Rate for Payer: Aetna Government |
$9,824.59
|
| Rate for Payer: Brighton Health Commercial |
$17,358.94
|
| Rate for Payer: Cash Price |
$9,824.59
|
| Rate for Payer: Cash Price |
$9,824.59
|
| Rate for Payer: Cash Price |
$9,824.59
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$9,824.59
|
| 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 |
$9,824.59
|
| Rate for Payer: EmblemHealth Commercial |
$1,505.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$8,350.90
|
| Rate for Payer: Fidelis Essential Plan QHP |
$8,743.89
|
| Rate for Payer: Fidelis Medicare Advantage |
$9,824.59
|
| Rate for Payer: Fidelis Qualified Health Plan |
$8,743.89
|
| Rate for Payer: Group Health Inc Commercial |
$9,824.59
|
| Rate for Payer: Group Health Inc Medicare |
$9,824.59
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$11,572.62
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$9,824.59
|
| Rate for Payer: Healthfirst Medicare Advantage |
$8,350.90
|
| Rate for Payer: Healthfirst QHP |
$9,824.59
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$9,824.59
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$9,824.59
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$7,859.67
|
| Rate for Payer: Wellcare Medicare |
$9,333.36
|
|
|
TEMPORARY PACEMAKER
|
Facility
|
IP
|
$23,145.25
|
|
|
Service Code
|
HCPCS 33210
|
| Hospital Charge Code |
30103039
|
|
Hospital Revenue Code
|
450
|
| Rate for Payer: Cash Price |
$9,824.59
|
|
|
TEMPORARY PACEMAKER
|
Facility
|
OP
|
$23,145.25
|
|
|
Service Code
|
HCPCS 33210
|
| Hospital Charge Code |
30103039
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$165.00 |
| Max. Negotiated Rate |
$11,572.62 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$5,593.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$9,824.59
|
| Rate for Payer: Aetna Government |
$9,824.59
|
| Rate for Payer: Brighton Health Commercial |
$874.00
|
| Rate for Payer: Carelon Behavioral Health CHP/Medicaid |
$9,824.59
|
| Rate for Payer: Carelon Behavioral Health Medicare Advantage |
$9,824.59
|
| Rate for Payer: Cash Price |
$9,824.59
|
| Rate for Payer: Cash Price |
$9,824.59
|
| Rate for Payer: Cash Price |
$9,824.59
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$9,824.59
|
| 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 |
$9,824.59
|
| Rate for Payer: EmblemHealth Commercial |
$525.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$8,350.90
|
| Rate for Payer: Fidelis Essential Plan QHP |
$8,743.89
|
| Rate for Payer: Fidelis Medicare Advantage |
$9,824.59
|
| Rate for Payer: Fidelis Qualified Health Plan |
$8,743.89
|
| Rate for Payer: Group Health Inc Commercial |
$525.00
|
| Rate for Payer: Group Health Inc Medicare |
$525.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$11,572.62
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$9,824.59
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$165.00
|
| Rate for Payer: Healthfirst Medicare Advantage |
$225.00
|
| Rate for Payer: Healthfirst QHP |
$9,824.59
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$9,824.59
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$9,824.59
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$9,824.59
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$7,859.67
|
| Rate for Payer: Wellcare Medicare |
$9,333.36
|
|
|
TEMPORARY PLATE HOLDER
|
Facility
|
OP
|
$547.00
|
|
| Hospital Charge Code |
40209358
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$191.45 |
| Max. Negotiated Rate |
$437.60 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$300.85
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$273.50
|
| Rate for Payer: Aetna Government |
$273.50
|
| Rate for Payer: Brighton Health Commercial |
$410.25
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$437.60
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$371.96
|
| Rate for Payer: Group Health Inc Commercial |
$273.50
|
| Rate for Payer: Group Health Inc Medicare |
$191.45
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$273.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$273.50
|
|
|
TEMPORARY RECON SCREW HOLDER
|
Facility
|
OP
|
$522.50
|
|
| Hospital Charge Code |
40202154
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$182.88 |
| Max. Negotiated Rate |
$418.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$287.38
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$261.25
|
| Rate for Payer: Aetna Government |
$261.25
|
| Rate for Payer: Brighton Health Commercial |
$391.88
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$418.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$355.30
|
| Rate for Payer: Group Health Inc Commercial |
$261.25
|
| Rate for Payer: Group Health Inc Medicare |
$182.88
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$261.25
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$261.25
|
|
|
TEMP SPINAL CORD STIMULATOR
|
Facility
|
IP
|
$18,739.28
|
|
|
Service Code
|
HCPCS 63650
|
| Hospital Charge Code |
40000465
|
|
Hospital Revenue Code
|
360
|
| Rate for Payer: Cash Price |
$7,908.94
|
|
|
TEMP SPINAL CORD STIMULATOR
|
Facility
|
OP
|
$18,739.28
|
|
|
Service Code
|
HCPCS 63650
|
| Hospital Charge Code |
40000465
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,505.00 |
| Max. Negotiated Rate |
$406,911.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,888.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$7,908.94
|
| Rate for Payer: Aetna Government |
$7,908.94
|
| Rate for Payer: Amida Care Medicaid |
$4,069.11
|
| Rate for Payer: Brighton Health Commercial |
$14,054.46
|
| Rate for Payer: Cash Price |
$7,908.94
|
| Rate for Payer: Cash Price |
$7,908.94
|
| Rate for Payer: Cash Price |
$7,908.94
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$7,908.94
|
| 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 |
$7,908.94
|
| Rate for Payer: EmblemHealth Commercial |
$1,505.00
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$406,911.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$4,069.11
|
| Rate for Payer: Fidelis Essential Plan QHP |
$4,069.11
|
| Rate for Payer: Fidelis Medicare Advantage |
$7,908.94
|
| Rate for Payer: Fidelis Qualified Health Plan |
$4,272.57
|
| Rate for Payer: Group Health Inc Commercial |
$7,908.94
|
| Rate for Payer: Group Health Inc Medicare |
$7,908.94
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4,069.11
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$7,908.94
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$4,069.11
|
| Rate for Payer: Healthfirst Essential Plan |
$9,155.50
|
| Rate for Payer: Healthfirst Medicare Advantage |
$6,722.60
|
| Rate for Payer: Healthfirst QHP |
$4,069.11
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$7,908.94
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$4,069.11
|
| Rate for Payer: SOMOS Essential |
$9,155.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$7,908.94
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$6,327.15
|
| Rate for Payer: Wellcare Medicare |
$7,513.49
|
|
|
TEMP TRANSCUTAN PACING
|
Facility
|
OP
|
$1,624.80
|
|
|
Service Code
|
HCPCS 92953
|
| Hospital Charge Code |
30103320
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$165.00 |
| Max. Negotiated Rate |
$874.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$694.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$752.63
|
| Rate for Payer: Aetna Government |
$752.63
|
| Rate for Payer: Brighton Health Commercial |
$874.00
|
| Rate for Payer: Carelon Behavioral Health CHP/Medicaid |
$752.63
|
| Rate for Payer: Carelon Behavioral Health Medicare Advantage |
$752.63
|
| Rate for Payer: Cash Price |
$752.63
|
| Rate for Payer: Cash Price |
$752.63
|
| Rate for Payer: Cash Price |
$752.63
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$752.63
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$747.30
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$635.21
|
| Rate for Payer: Elderplan Medicare Advantage |
$752.63
|
| Rate for Payer: EmblemHealth Commercial |
$525.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$639.74
|
| Rate for Payer: Fidelis Essential Plan QHP |
$669.84
|
| Rate for Payer: Fidelis Medicare Advantage |
$752.63
|
| Rate for Payer: Fidelis Qualified Health Plan |
$669.84
|
| Rate for Payer: Group Health Inc Commercial |
$525.00
|
| Rate for Payer: Group Health Inc Medicare |
$525.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$812.40
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$752.63
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$165.00
|
| Rate for Payer: Healthfirst Medicare Advantage |
$225.00
|
| Rate for Payer: Healthfirst QHP |
$752.63
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$752.63
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$752.63
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$752.63
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$602.10
|
| Rate for Payer: Wellcare Medicare |
$715.00
|
|
|
TEMP TRANSCUTAN PACING
|
Facility
|
IP
|
$1,624.80
|
|
|
Service Code
|
HCPCS 92953
|
| Hospital Charge Code |
30103320
|
|
Hospital Revenue Code
|
450
|
| Rate for Payer: Cash Price |
$752.63
|
|
|
TEMSIROLIMUS 25MG INJ - PER 1 MG
|
Facility
|
IP
|
$77.28
|
|
|
Service Code
|
HCPCS J9330
|
| Hospital Charge Code |
41658015
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$38.64 |
| Max. Negotiated Rate |
$38.64 |
| Rate for Payer: Cash Price |
$30.99
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$38.64
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$38.64
|
|
|
TEMSIROLIMUS 25MG INJ - PER 1 MG
|
Facility
|
OP
|
$77.28
|
|
|
Service Code
|
HCPCS J9330
|
| Hospital Charge Code |
41658015
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.79 |
| Max. Negotiated Rate |
$50.23 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$42.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$30.99
|
| Rate for Payer: Aetna Government |
$30.99
|
| Rate for Payer: Brighton Health Commercial |
$46.37
|
| Rate for Payer: Cash Price |
$30.99
|
| Rate for Payer: Cash Price |
$30.99
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$30.99
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$38.64
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$44.44
|
| Rate for Payer: Elderplan Medicare Advantage |
$30.99
|
| Rate for Payer: EmblemHealth Commercial |
$30.99
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$30.99
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$30.99
|
| Rate for Payer: Fidelis Essential Plan QHP |
$32.54
|
| Rate for Payer: Fidelis Medicare Advantage |
$30.99
|
| Rate for Payer: Fidelis Qualified Health Plan |
$32.54
|
| Rate for Payer: Group Health Inc Commercial |
$30.99
|
| Rate for Payer: Group Health Inc Medicare |
$30.99
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$38.64
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$38.64
|
| Rate for Payer: Healthfirst Medicare Advantage |
$26.34
|
| Rate for Payer: Healthfirst QHP |
$30.99
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$30.99
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$30.59
|
| Rate for Payer: SOMOS Essential |
$30.59
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$50.23
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$24.79
|
| Rate for Payer: Wellcare Medicare |
$29.44
|
|
|
TEMSIROLIMUS 25MG INJ - PER 1MG
|
Facility
|
OP
|
$77.28
|
|
|
Service Code
|
HCPCS J9330
|
| Hospital Charge Code |
41648015
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.79 |
| Max. Negotiated Rate |
$50.23 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$42.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$30.99
|
| Rate for Payer: Aetna Government |
$30.99
|
| Rate for Payer: Brighton Health Commercial |
$46.37
|
| Rate for Payer: Cash Price |
$30.99
|
| Rate for Payer: Cash Price |
$30.99
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$30.99
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$38.64
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$44.44
|
| Rate for Payer: Elderplan Medicare Advantage |
$30.99
|
| Rate for Payer: EmblemHealth Commercial |
$30.99
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$30.99
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$30.99
|
| Rate for Payer: Fidelis Essential Plan QHP |
$32.54
|
| Rate for Payer: Fidelis Medicare Advantage |
$30.99
|
| Rate for Payer: Fidelis Qualified Health Plan |
$32.54
|
| Rate for Payer: Group Health Inc Commercial |
$30.99
|
| Rate for Payer: Group Health Inc Medicare |
$30.99
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$38.64
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$38.64
|
| Rate for Payer: Healthfirst Medicare Advantage |
$26.34
|
| Rate for Payer: Healthfirst QHP |
$30.99
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$30.99
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$30.59
|
| Rate for Payer: SOMOS Essential |
$30.59
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$50.23
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$24.79
|
| Rate for Payer: Wellcare Medicare |
$29.44
|
|
|
TEMSIROLIMUS 25MG INJ - PER 1MG
|
Facility
|
IP
|
$77.28
|
|
|
Service Code
|
HCPCS J9330
|
| Hospital Charge Code |
41648015
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$38.64 |
| Max. Negotiated Rate |
$38.64 |
| Rate for Payer: Cash Price |
$30.99
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$38.64
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$38.64
|
|
|
TEMSIROLIMUS 25 MG/ML IV SOLN [82228]
|
Facility
|
IP
|
$2,400.38
|
|
|
Service Code
|
HCPCS J9330
|
| Hospital Charge Code |
00008117901
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,200.19 |
| Max. Negotiated Rate |
$1,200.19 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,200.19
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,200.19
|
|
|
TEMSIROLIMUS 25 MG/ML IV SOLN [82228]
|
Facility
|
OP
|
$2,400.38
|
|
|
Service Code
|
HCPCS J9330
|
| Hospital Charge Code |
00008117901
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$24.79 |
| Max. Negotiated Rate |
$1,560.25 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,320.21
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$30.99
|
| Rate for Payer: Aetna Government |
$30.99
|
| Rate for Payer: Brighton Health Commercial |
$1,440.23
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$30.99
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,200.19
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,380.22
|
| Rate for Payer: Elderplan Medicare Advantage |
$30.99
|
| Rate for Payer: EmblemHealth Commercial |
$1,200.19
|
| Rate for Payer: Fidelis Medicare Advantage |
$30.99
|
| Rate for Payer: Group Health Inc Commercial |
$30.99
|
| Rate for Payer: Group Health Inc Medicare |
$30.99
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,200.19
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,200.19
|
| Rate for Payer: Healthfirst Medicare Advantage |
$26.34
|
| Rate for Payer: Healthfirst QHP |
$30.99
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$30.99
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,560.25
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$24.79
|
|
|
TENCKHOFF CATHETER
|
Facility
|
OP
|
$80.44
|
|
| Hospital Charge Code |
40207003
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$28.15 |
| Max. Negotiated Rate |
$64.35 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$44.24
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$40.22
|
| Rate for Payer: Aetna Government |
$40.22
|
| Rate for Payer: Brighton Health Commercial |
$60.33
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$64.35
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$54.70
|
| Rate for Payer: Group Health Inc Commercial |
$40.22
|
| Rate for Payer: Group Health Inc Medicare |
$28.15
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$40.22
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$40.22
|
|
