|
TOCILIZUMAB 80MG/4ML
|
Facility
|
OP
|
$14.22
|
|
|
Service Code
|
HCPCS J3262
|
| Hospital Charge Code |
41650246
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.90 |
| Max. Negotiated Rate |
$9.24 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$7.82
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$6.12
|
| Rate for Payer: Aetna Government |
$6.12
|
| Rate for Payer: Brighton Health Commercial |
$8.53
|
| Rate for Payer: Cash Price |
$6.12
|
| Rate for Payer: Cash Price |
$6.12
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$6.12
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$7.11
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$8.18
|
| Rate for Payer: Elderplan Medicare Advantage |
$6.12
|
| Rate for Payer: EmblemHealth Commercial |
$6.12
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$6.12
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$6.12
|
| Rate for Payer: Fidelis Essential Plan QHP |
$6.43
|
| Rate for Payer: Fidelis Medicare Advantage |
$6.12
|
| Rate for Payer: Fidelis Qualified Health Plan |
$6.43
|
| Rate for Payer: Group Health Inc Commercial |
$6.12
|
| Rate for Payer: Group Health Inc Medicare |
$6.12
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$7.11
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$7.11
|
| Rate for Payer: Healthfirst Medicare Advantage |
$5.20
|
| Rate for Payer: Healthfirst QHP |
$6.12
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$6.12
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$6.40
|
| Rate for Payer: SOMOS Essential |
$6.40
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$9.24
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$4.90
|
| Rate for Payer: Wellcare Medicare |
$5.81
|
|
|
TOCILIZUMAB 80MG/4ML
|
Facility
|
IP
|
$14.22
|
|
|
Service Code
|
HCPCS J3262
|
| Hospital Charge Code |
41650246
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.11 |
| Max. Negotiated Rate |
$7.11 |
| Rate for Payer: Cash Price |
$6.12
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$7.11
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$7.11
|
|
|
TOCILIZUMAB 80MG/4ML
|
Facility
|
OP
|
$14.22
|
|
|
Service Code
|
HCPCS J3262
|
| Hospital Charge Code |
41640246
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.90 |
| Max. Negotiated Rate |
$9.24 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$7.82
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$6.12
|
| Rate for Payer: Aetna Government |
$6.12
|
| Rate for Payer: Brighton Health Commercial |
$8.53
|
| Rate for Payer: Cash Price |
$6.12
|
| Rate for Payer: Cash Price |
$6.12
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$6.12
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$7.11
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$8.18
|
| Rate for Payer: Elderplan Medicare Advantage |
$6.12
|
| Rate for Payer: EmblemHealth Commercial |
$6.12
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$6.12
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$6.12
|
| Rate for Payer: Fidelis Essential Plan QHP |
$6.43
|
| Rate for Payer: Fidelis Medicare Advantage |
$6.12
|
| Rate for Payer: Fidelis Qualified Health Plan |
$6.43
|
| Rate for Payer: Group Health Inc Commercial |
$6.12
|
| Rate for Payer: Group Health Inc Medicare |
$6.12
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$7.11
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$7.11
|
| Rate for Payer: Healthfirst Medicare Advantage |
$5.20
|
| Rate for Payer: Healthfirst QHP |
$6.12
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$6.12
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$6.40
|
| Rate for Payer: SOMOS Essential |
$6.40
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$9.24
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$4.90
|
| Rate for Payer: Wellcare Medicare |
$5.81
|
|
|
TOCILIZUMAB 80MG/4ML
|
Facility
|
IP
|
$14.22
|
|
|
Service Code
|
HCPCS J3262
|
| Hospital Charge Code |
41640246
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.11 |
| Max. Negotiated Rate |
$7.11 |
| Rate for Payer: Cash Price |
$6.12
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$7.11
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$7.11
|
|
|
TOCILIZUMAB 80 MG/4ML IV SOLN [108061]
|
Facility
|
OP
|
$159.35
|
|
|
Service Code
|
HCPCS J3262
|
| Hospital Charge Code |
50242013501
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4.90 |
| Max. Negotiated Rate |
$103.58 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$87.64
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$6.12
|
| Rate for Payer: Aetna Government |
$6.12
|
| Rate for Payer: Brighton Health Commercial |
$95.61
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$6.12
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$79.67
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$91.63
|
| Rate for Payer: Elderplan Medicare Advantage |
$6.12
|
| Rate for Payer: EmblemHealth Commercial |
$79.67
|
| Rate for Payer: Fidelis Medicare Advantage |
$6.12
|
| Rate for Payer: Group Health Inc Commercial |
$6.12
|
| Rate for Payer: Group Health Inc Medicare |
$6.12
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$79.67
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$79.67
|
| Rate for Payer: Healthfirst Medicare Advantage |
$5.20
|
| Rate for Payer: Healthfirst QHP |
$6.12
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$6.12
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$103.58
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$4.90
|
|
|
TOCILIZUMAB 80 MG/4ML IV SOLN [108061]
|
Facility
|
IP
|
$159.35
|
|
|
Service Code
|
HCPCS J3262
|
| Hospital Charge Code |
50242013501
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$79.67 |
| Max. Negotiated Rate |
$79.67 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$79.67
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$79.67
|
|
|
TOCILIZUMAB/PLACEBO (TRIAL)
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
HCPCS J3262
|
| Hospital Charge Code |
41640350
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$6.43 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.01
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$6.12
|
| Rate for Payer: Aetna Government |
$6.12
|
| Rate for Payer: Brighton Health Commercial |
$0.01
|
| Rate for Payer: Cash Price |
$6.12
|
| Rate for Payer: Cash Price |
$6.12
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$6.12
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.01
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.01
|
| Rate for Payer: Elderplan Medicare Advantage |
$6.12
|
| Rate for Payer: EmblemHealth Commercial |
$6.12
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$6.12
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$6.12
|
| Rate for Payer: Fidelis Essential Plan QHP |
$6.43
|
| Rate for Payer: Fidelis Medicare Advantage |
$6.12
|
| Rate for Payer: Fidelis Qualified Health Plan |
$6.43
|
| Rate for Payer: Group Health Inc Commercial |
$6.12
|
| Rate for Payer: Group Health Inc Medicare |
$6.12
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.01
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.01
|
| Rate for Payer: Healthfirst Medicare Advantage |
$5.20
|
| Rate for Payer: Healthfirst QHP |
$6.12
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$6.12
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$6.40
|
| Rate for Payer: SOMOS Essential |
$6.40
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.01
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$4.90
|
| Rate for Payer: Wellcare Medicare |
$5.81
|
|
|
TOCILIZUMAB/PLACEBO (TRIAL)
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
HCPCS J3262
|
| Hospital Charge Code |
41640350
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Cash Price |
$6.12
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.01
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.01
|
|
|
TOCILIZUMAB/PLACEBO (TRIAL)
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
HCPCS J3262
|
| Hospital Charge Code |
41650350
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Cash Price |
$6.12
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.01
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.01
|
|
|
TOCILIZUMAB/PLACEBO (TRIAL)
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
HCPCS J3262
|
| Hospital Charge Code |
41650350
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$6.43 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.01
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$6.12
|
| Rate for Payer: Aetna Government |
$6.12
|
| Rate for Payer: Brighton Health Commercial |
$0.01
|
| Rate for Payer: Cash Price |
$6.12
|
| Rate for Payer: Cash Price |
$6.12
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$6.12
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.01
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.01
|
| Rate for Payer: Elderplan Medicare Advantage |
$6.12
|
| Rate for Payer: EmblemHealth Commercial |
$6.12
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$6.12
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$6.12
|
| Rate for Payer: Fidelis Essential Plan QHP |
$6.43
|
| Rate for Payer: Fidelis Medicare Advantage |
$6.12
|
| Rate for Payer: Fidelis Qualified Health Plan |
$6.43
|
| Rate for Payer: Group Health Inc Commercial |
$6.12
|
| Rate for Payer: Group Health Inc Medicare |
$6.12
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.01
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.01
|
| Rate for Payer: Healthfirst Medicare Advantage |
$5.20
|
| Rate for Payer: Healthfirst QHP |
$6.12
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$6.12
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$6.40
|
| Rate for Payer: SOMOS Essential |
$6.40
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.01
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$4.90
|
| Rate for Payer: Wellcare Medicare |
$5.81
|
|
|
TOE IMPLANT, FLEX HINGED
|
Facility
|
OP
|
$315.75
|
|
| Hospital Charge Code |
40202112
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$110.51 |
| Max. Negotiated Rate |
$252.60 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$173.66
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$157.88
|
| Rate for Payer: Aetna Government |
$157.88
|
| Rate for Payer: Brighton Health Commercial |
$236.81
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$252.60
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$214.71
|
| Rate for Payer: Group Health Inc Commercial |
$157.88
|
| Rate for Payer: Group Health Inc Medicare |
$110.51
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$157.88
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$157.88
|
|
|
TOE IMPLANT, GREAT
|
Facility
|
OP
|
$282.44
|
|
| Hospital Charge Code |
40202122
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$98.85 |
| Max. Negotiated Rate |
$225.95 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$155.34
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$141.22
|
| Rate for Payer: Aetna Government |
$141.22
|
| Rate for Payer: Brighton Health Commercial |
$211.83
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$225.95
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$192.06
|
| Rate for Payer: Group Health Inc Commercial |
$141.22
|
| Rate for Payer: Group Health Inc Medicare |
$98.85
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$141.22
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$141.22
|
|
|
TOE M-P JNT MED20MM POROUS COTED
|
Facility
|
IP
|
$2,150.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
40200807
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,075.00 |
| Max. Negotiated Rate |
$1,075.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,075.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,075.00
|
|
|
TOE M-P JNT MED20MM POROUS COTED
|
Facility
|
OP
|
$2,150.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
40200807
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$134.20 |
| Max. Negotiated Rate |
$2,257.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,182.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$134.20
|
| Rate for Payer: Aetna Government |
$134.20
|
| Rate for Payer: Brighton Health Commercial |
$1,290.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,075.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,236.25
|
| Rate for Payer: EmblemHealth Commercial |
$1,075.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$2,257.50
|
| Rate for Payer: Group Health Inc Commercial |
$1,075.00
|
| Rate for Payer: Group Health Inc Medicare |
$752.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,075.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,075.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,397.50
|
|
|
TOLVAPTAN 15 MG PO TABS [97893]
|
Facility
|
OP
|
$561.78
|
|
|
Service Code
|
NDC 49884076854
|
| Hospital Charge Code |
49884076854
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$196.62 |
| Max. Negotiated Rate |
$449.42 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$308.98
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$280.89
|
| Rate for Payer: Aetna Government |
$280.89
|
| Rate for Payer: Brighton Health Commercial |
$421.34
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$449.42
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$382.01
|
| Rate for Payer: Group Health Inc Commercial |
$280.89
|
| Rate for Payer: Group Health Inc Medicare |
$196.62
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$280.89
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$280.89
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$365.16
|
|
|
TOLVAPTAN 15 MG PO TABS [97893]
|
Facility
|
OP
|
$624.24
|
|
|
Service Code
|
NDC 59148002050
|
| Hospital Charge Code |
59148002050
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$218.48 |
| Max. Negotiated Rate |
$499.39 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$343.33
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$312.12
|
| Rate for Payer: Aetna Government |
$312.12
|
| Rate for Payer: Brighton Health Commercial |
$468.18
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$499.39
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$424.48
|
| Rate for Payer: Group Health Inc Commercial |
$312.12
|
| Rate for Payer: Group Health Inc Medicare |
$218.48
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$312.12
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$312.12
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$405.75
|
|
|
TOLVAPTAN 15 MG TAB
|
Facility
|
OP
|
$535.31
|
|
| Hospital Charge Code |
41645592
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$187.36 |
| Max. Negotiated Rate |
$428.25 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$294.42
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$267.66
|
| Rate for Payer: Aetna Government |
$267.66
|
| Rate for Payer: Brighton Health Commercial |
$401.48
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$428.25
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$364.01
|
| Rate for Payer: Group Health Inc Commercial |
$267.66
|
| Rate for Payer: Group Health Inc Medicare |
$187.36
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$267.66
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$267.66
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$347.95
|
|
|
TOLVAPTAN 15 MG TAB
|
Facility
|
OP
|
$535.31
|
|
| Hospital Charge Code |
41655592
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$187.36 |
| Max. Negotiated Rate |
$428.25 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$294.42
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$267.66
|
| Rate for Payer: Aetna Government |
$267.66
|
| Rate for Payer: Brighton Health Commercial |
$401.48
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$428.25
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$364.01
|
| Rate for Payer: Group Health Inc Commercial |
$267.66
|
| Rate for Payer: Group Health Inc Medicare |
$187.36
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$267.66
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$267.66
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$347.95
|
|
|
TOLVAPTAN 30 MG PO TABS [97894]
|
Facility
|
OP
|
$582.75
|
|
|
Service Code
|
NDC 31722086903
|
| Hospital Charge Code |
31722086903
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$203.96 |
| Max. Negotiated Rate |
$466.20 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$320.51
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$291.38
|
| Rate for Payer: Aetna Government |
$291.38
|
| Rate for Payer: Brighton Health Commercial |
$437.06
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$466.20
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$396.27
|
| Rate for Payer: Group Health Inc Commercial |
$291.38
|
| Rate for Payer: Group Health Inc Medicare |
$203.96
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$291.38
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$291.38
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$378.79
|
|
|
TOLVAPTAN 30 MG PO TABS [97894]
|
Facility
|
OP
|
$647.57
|
|
|
Service Code
|
NDC 59148002150
|
| Hospital Charge Code |
59148002150
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$226.65 |
| Max. Negotiated Rate |
$518.06 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$356.16
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$323.79
|
| Rate for Payer: Aetna Government |
$323.79
|
| Rate for Payer: Brighton Health Commercial |
$485.68
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$518.06
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$440.35
|
| Rate for Payer: Group Health Inc Commercial |
$323.79
|
| Rate for Payer: Group Health Inc Medicare |
$226.65
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$323.79
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$323.79
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$420.92
|
|
|
TOLVAPTAN 30 MG TAB
|
Facility
|
OP
|
$535.31
|
|
| Hospital Charge Code |
41645593
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$187.36 |
| Max. Negotiated Rate |
$428.25 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$294.42
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$267.66
|
| Rate for Payer: Aetna Government |
$267.66
|
| Rate for Payer: Brighton Health Commercial |
$401.48
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$428.25
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$364.01
|
| Rate for Payer: Group Health Inc Commercial |
$267.66
|
| Rate for Payer: Group Health Inc Medicare |
$187.36
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$267.66
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$267.66
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$347.95
|
|
|
TOLVAPTAN 30 MG TAB
|
Facility
|
OP
|
$535.31
|
|
| Hospital Charge Code |
41655593
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$187.36 |
| Max. Negotiated Rate |
$428.25 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$294.42
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$267.66
|
| Rate for Payer: Aetna Government |
$267.66
|
| Rate for Payer: Brighton Health Commercial |
$401.48
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$428.25
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$364.01
|
| Rate for Payer: Group Health Inc Commercial |
$267.66
|
| Rate for Payer: Group Health Inc Medicare |
$187.36
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$267.66
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$267.66
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$347.95
|
|
|
TOMOGRAPHIC SURVEY
|
Facility
|
IP
|
$732.85
|
|
|
Service Code
|
HCPCS D0322
|
| Hospital Charge Code |
42300180
|
|
Hospital Revenue Code
|
361
|
| Rate for Payer: Cash Price |
$127.14
|
|
|
TOMOGRAPHIC SURVEY
|
Facility
|
OP
|
$732.85
|
|
|
Service Code
|
HCPCS D0322
|
| Hospital Charge Code |
42300180
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$101.71 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$403.07
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$127.14
|
| Rate for Payer: Aetna Government |
$127.14
|
| Rate for Payer: Brighton Health Commercial |
$549.64
|
| Rate for Payer: Cash Price |
$127.14
|
| Rate for Payer: Cash Price |
$127.14
|
| Rate for Payer: Cash Price |
$127.14
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$127.14
|
| 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 |
$127.14
|
| Rate for Payer: EmblemHealth Commercial |
$127.14
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$108.07
|
| Rate for Payer: Fidelis Essential Plan QHP |
$113.15
|
| Rate for Payer: Fidelis Medicare Advantage |
$127.14
|
| Rate for Payer: Fidelis Qualified Health Plan |
$113.15
|
| Rate for Payer: Group Health Inc Commercial |
$127.14
|
| Rate for Payer: Group Health Inc Medicare |
$127.14
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$366.42
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$127.14
|
| Rate for Payer: Healthfirst Medicare Advantage |
$108.07
|
| Rate for Payer: Healthfirst QHP |
$127.14
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$127.14
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$127.14
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$101.71
|
| Rate for Payer: Wellcare Medicare |
$120.78
|
|
|
TONE DECAY
|
Facility
|
OP
|
$101.25
|
|
|
Service Code
|
HCPCS 92563
|
| Hospital Charge Code |
42003100
|
|
Hospital Revenue Code
|
471
|
| Min. Negotiated Rate |
$37.10 |
| Max. Negotiated Rate |
$81.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$55.69
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$46.38
|
| Rate for Payer: Aetna Government |
$46.38
|
| Rate for Payer: Brighton Health Commercial |
$75.94
|
| Rate for Payer: Cash Price |
$46.38
|
| Rate for Payer: Cash Price |
$46.38
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$46.38
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$81.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$68.85
|
| Rate for Payer: Elderplan Medicare Advantage |
$46.38
|
| Rate for Payer: EmblemHealth Commercial |
$46.38
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$39.42
|
| Rate for Payer: Fidelis Essential Plan QHP |
$41.28
|
| Rate for Payer: Fidelis Medicare Advantage |
$46.38
|
| Rate for Payer: Fidelis Qualified Health Plan |
$41.28
|
| Rate for Payer: Group Health Inc Commercial |
$46.38
|
| Rate for Payer: Group Health Inc Medicare |
$46.38
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$50.62
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$46.38
|
| Rate for Payer: Healthfirst Medicare Advantage |
$39.42
|
| Rate for Payer: Healthfirst QHP |
$46.38
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$46.38
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$46.38
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$37.10
|
| Rate for Payer: Wellcare Medicare |
$44.06
|
|
