|
TETANUS-DIPHTHERIA TOXOIDS TD 2-2 LF/0.5ML IM SUSP [37504]
|
Facility
|
OP
|
$67.16
|
|
|
Service Code
|
HCPCS 90714
|
| Hospital Charge Code |
13533013101
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.83 |
| Max. Negotiated Rate |
$53.73 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$36.94
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$26.22
|
| Rate for Payer: Aetna Government |
$26.22
|
| Rate for Payer: Brighton Health Commercial |
$50.37
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$53.73
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$45.67
|
| Rate for Payer: Group Health Inc Commercial |
$33.58
|
| Rate for Payer: Group Health Inc Medicare |
$23.51
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$33.58
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$33.58
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$18.83
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$19.96
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$19.96
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$19.96
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$43.66
|
|
|
TETANUS-DIPHTHERIA TOXOIDS TD 5-2 LFU IM INJ [11515]
|
Facility
|
OP
|
$88.44
|
|
|
Service Code
|
HCPCS 90714
|
| Hospital Charge Code |
49281021510
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.83 |
| Max. Negotiated Rate |
$70.76 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$48.64
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$26.22
|
| Rate for Payer: Aetna Government |
$26.22
|
| Rate for Payer: Brighton Health Commercial |
$66.33
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$70.76
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$60.14
|
| Rate for Payer: Group Health Inc Commercial |
$44.22
|
| Rate for Payer: Group Health Inc Medicare |
$30.96
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$44.22
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$44.22
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$18.83
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$19.96
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$19.96
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$19.96
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$57.49
|
|
|
TETANUS-DIPHTHERIA TOXOIDS TD 5-2 LFU IM INJ [11515]
|
Facility
|
OP
|
$88.44
|
|
|
Service Code
|
HCPCS 90714
|
| Hospital Charge Code |
49281021558
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.83 |
| Max. Negotiated Rate |
$70.76 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$48.64
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$26.22
|
| Rate for Payer: Aetna Government |
$26.22
|
| Rate for Payer: Brighton Health Commercial |
$66.33
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$70.76
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$60.14
|
| Rate for Payer: Group Health Inc Commercial |
$44.22
|
| Rate for Payer: Group Health Inc Medicare |
$30.96
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$44.22
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$44.22
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$18.83
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$19.96
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$19.96
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$19.96
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$57.49
|
|
|
TETANUS-DIPHTHERIA TOXOIDS TD 5-2 LFU IM INJ [11515]
|
Facility
|
OP
|
$88.44
|
|
|
Service Code
|
HCPCS 90714
|
| Hospital Charge Code |
49281021515
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.83 |
| Max. Negotiated Rate |
$70.76 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$48.64
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$26.22
|
| Rate for Payer: Aetna Government |
$26.22
|
| Rate for Payer: Brighton Health Commercial |
$66.33
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$70.76
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$60.14
|
| Rate for Payer: Group Health Inc Commercial |
$44.22
|
| Rate for Payer: Group Health Inc Medicare |
$30.96
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$44.22
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$44.22
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$18.83
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$19.96
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$19.96
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$19.96
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$57.49
|
|
|
TETANUS-DIPHTHERIA TOXOIDS TD 5-2 LFU IM INJ [11515]
|
Facility
|
OP
|
$88.44
|
|
|
Service Code
|
HCPCS 90714
|
| Hospital Charge Code |
49281021588
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.83 |
| Max. Negotiated Rate |
$70.76 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$48.64
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$26.22
|
| Rate for Payer: Aetna Government |
$26.22
|
| Rate for Payer: Brighton Health Commercial |
$66.33
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$70.76
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$60.14
|
| Rate for Payer: Group Health Inc Commercial |
$44.22
|
| Rate for Payer: Group Health Inc Medicare |
$30.96
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$44.22
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$44.22
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$18.83
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$19.96
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$19.96
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$19.96
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$57.49
|
|
|
TETANUS IG IM
|
Facility
|
OP
|
$107.64
|
|
|
Service Code
|
HCPCS 90389
|
| Hospital Charge Code |
30105773
|
|
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: Brighton Health Commercial |
$80.73
|
| 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
|
|
|
TETANUS IMMUNE GLOBULIN 250 UNIT/ML IM SOSY [180686]
|
Facility
|
OP
|
$779.00
|
|
|
Service Code
|
HCPCS J1670
|
| Hospital Charge Code |
13533063402
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$389.50 |
| Max. Negotiated Rate |
$623.20 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$428.45
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$578.61
|
| Rate for Payer: Aetna Government |
$578.61
|
| Rate for Payer: Brighton Health Commercial |
$584.25
|
| 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 |
$623.20
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$529.72
|
| Rate for Payer: Elderplan Medicare Advantage |
$578.61
|
| Rate for Payer: EmblemHealth Commercial |
$578.61
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$491.82
|
| Rate for Payer: Fidelis Essential Plan QHP |
$514.97
|
| Rate for Payer: Fidelis Medicare Advantage |
$578.61
|
| Rate for Payer: Fidelis Qualified Health Plan |
$514.97
|
| 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 |
$389.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$578.61
|
| Rate for Payer: Healthfirst Medicare Advantage |
$491.82
|
| Rate for Payer: Healthfirst QHP |
$578.61
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$578.78
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$613.51
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$613.51
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$613.51
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$578.61
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$506.35
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$462.89
|
| Rate for Payer: Wellcare Medicare |
$549.68
|
|
|
TETANUS IMMUNE GLOBULIN 250 UNITS INJ
|
Facility
|
IP
|
$650.12
|
|
|
Service Code
|
HCPCS J1670
|
| Hospital Charge Code |
41644396
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$325.06 |
| Max. Negotiated Rate |
$325.06 |
| Rate for Payer: Cash Price |
$578.61
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$325.06
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$325.06
|
|
|
TETANUS IMMUNE GLOBULIN 250 UNITS INJ
|
Facility
|
IP
|
$650.12
|
|
|
Service Code
|
HCPCS J1670
|
| Hospital Charge Code |
41654396
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$325.06 |
| Max. Negotiated Rate |
$325.06 |
| Rate for Payer: Cash Price |
$578.61
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$325.06
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$325.06
|
|
|
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: Brighton Health Commercial |
$390.07
|
| 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 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 IMMUNE GLOBULIN 250 UNITS INJ
|
Facility
|
OP
|
$650.12
|
|
|
Service Code
|
HCPCS J1670
|
| Hospital Charge Code |
41654396
|
|
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: Brighton Health Commercial |
$390.07
|
| 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 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: Brighton Health Commercial |
$35.38
|
| 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: Brighton Health Commercial |
$40.50
|
| 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: Brighton Health Commercial |
$40.50
|
| 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: Brighton Health Commercial |
$80.73
|
| 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: Brighton Health Commercial |
$11.25
|
| 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: Brighton Health Commercial |
$11.25
|
| 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 |
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: Brighton Health Commercial |
$8.12
|
| 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 |
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: Brighton Health Commercial |
$8.12
|
| 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 |
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: Brighton Health Commercial |
$6.75
|
| 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 |
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: Brighton Health Commercial |
$6.75
|
| 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 |
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: Brighton Health Commercial |
$63.00
|
| 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 |
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: Brighton Health Commercial |
$63.00
|
| 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: Brighton Health Commercial |
$7.84
|
| 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 % OP SOLN [7795]
|
Facility
|
OP
|
$7.20
|
|
|
Service Code
|
NDC 68682092005
|
| Hospital Charge Code |
68682092005
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.52 |
| Max. Negotiated Rate |
$5.76 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$3.96
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3.60
|
| Rate for Payer: Aetna Government |
$3.60
|
| Rate for Payer: Brighton Health Commercial |
$5.40
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$5.76
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$4.90
|
| Rate for Payer: Group Health Inc Commercial |
$3.60
|
| Rate for Payer: Group Health Inc Medicare |
$2.52
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$3.60
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$3.60
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$4.68
|
|
