|
TRACHEOTOMY TUBING #72
|
Facility
|
OP
|
$126.51
|
|
| Hospital Charge Code |
40206006
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$44.28 |
| Max. Negotiated Rate |
$101.21 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$69.58
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$63.26
|
| Rate for Payer: Aetna Government |
$63.26
|
| Rate for Payer: Brighton Health Commercial |
$94.88
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$101.21
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$86.03
|
| Rate for Payer: Group Health Inc Commercial |
$63.26
|
| Rate for Payer: Group Health Inc Medicare |
$44.28
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$63.26
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$63.26
|
|
|
TRACHETOMY CLEANING SET
|
Facility
|
OP
|
$18.78
|
|
| Hospital Charge Code |
40206040
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$6.57 |
| Max. Negotiated Rate |
$15.02 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$10.33
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$9.39
|
| Rate for Payer: Aetna Government |
$9.39
|
| Rate for Payer: Brighton Health Commercial |
$14.08
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$15.02
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$12.77
|
| Rate for Payer: Group Health Inc Commercial |
$9.39
|
| Rate for Payer: Group Health Inc Medicare |
$6.57
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$9.39
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$9.39
|
|
|
TRACH PUNCT, PERC W TT ASP OR INJ
|
Facility
|
OP
|
$7,933.18
|
|
|
Service Code
|
HCPCS 31612
|
| Hospital Charge Code |
30103313
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$165.00 |
| Max. Negotiated Rate |
$3,966.59 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,412.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3,723.23
|
| Rate for Payer: Aetna Government |
$3,723.23
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$2,606.26
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$2,606.26
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$2,606.26
|
| Rate for Payer: Brighton Health Commercial |
$874.00
|
| Rate for Payer: Carelon Behavioral Health CHP/Medicaid |
$3,723.23
|
| Rate for Payer: Carelon Behavioral Health Medicare Advantage |
$3,723.23
|
| Rate for Payer: Cash Price |
$3,723.23
|
| Rate for Payer: Cash Price |
$3,723.23
|
| Rate for Payer: Cash Price |
$3,723.23
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$3,723.23
|
| 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 |
$3,723.23
|
| Rate for Payer: EmblemHealth Commercial |
$525.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$3,164.75
|
| Rate for Payer: Fidelis Essential Plan QHP |
$3,313.67
|
| Rate for Payer: Fidelis Medicare Advantage |
$3,723.23
|
| Rate for Payer: Fidelis Qualified Health Plan |
$3,313.67
|
| 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 |
$3,966.59
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$3,723.23
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$165.00
|
| Rate for Payer: Healthfirst Medicare Advantage |
$225.00
|
| Rate for Payer: Healthfirst QHP |
$3,723.23
|
| Rate for Payer: Humana Medicare |
$3,797.69
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$3,723.23
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$3,723.23
|
| Rate for Payer: United Healthcare Commercial |
$569.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,723.23
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3,723.23
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$2,978.58
|
| Rate for Payer: Wellcare Medicare |
$3,537.07
|
|
|
TRACH PUNCT, PERC W TT ASP OR INJ
|
Facility
|
IP
|
$7,933.18
|
|
|
Service Code
|
HCPCS 31612
|
| Hospital Charge Code |
30103313
|
|
Hospital Revenue Code
|
450
|
| Rate for Payer: Cash Price |
$3,723.23
|
|
|
TRACH TUBE
|
Facility
|
IP
|
$616.78
|
|
|
Service Code
|
HCPCS 31502
|
| Hospital Charge Code |
40306213
|
|
Hospital Revenue Code
|
419
|
| Rate for Payer: Cash Price |
$282.47
|
|
|
TRACH TUBE
|
Facility
|
OP
|
$616.78
|
|
|
Service Code
|
HCPCS 31502
|
| Hospital Charge Code |
40306213
|
|
Hospital Revenue Code
|
419
|
| Min. Negotiated Rate |
$197.73 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$342.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$282.47
|
| Rate for Payer: Aetna Government |
$282.47
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$197.73
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$197.73
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$197.73
|
| Rate for Payer: Brighton Health Commercial |
$462.58
|
| Rate for Payer: Cash Price |
$282.47
|
| Rate for Payer: Cash Price |
$282.47
|
| Rate for Payer: Cash Price |
$282.47
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$282.47
|
| 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 |
$282.47
|
| Rate for Payer: EmblemHealth Commercial |
$282.47
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$240.10
|
| Rate for Payer: Fidelis Essential Plan QHP |
$251.40
|
| Rate for Payer: Fidelis Medicare Advantage |
$282.47
|
| Rate for Payer: Fidelis Qualified Health Plan |
$251.40
|
| Rate for Payer: Group Health Inc Commercial |
$282.47
|
| Rate for Payer: Group Health Inc Medicare |
$282.47
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$308.39
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$282.47
|
| Rate for Payer: Healthfirst Medicare Advantage |
$240.10
|
| Rate for Payer: Healthfirst QHP |
$282.47
|
| Rate for Payer: Humana Medicare |
$288.12
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$282.47
|
| Rate for Payer: United Healthcare Commercial |
$308.39
|
| Rate for Payer: United Healthcare Medicare Advantage |
$282.47
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$282.47
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$225.98
|
| Rate for Payer: Wellcare Medicare |
$268.35
|
|
|
TRACTION SET UP
|
Facility
|
OP
|
$25.52
|
|
| Hospital Charge Code |
40207622
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$8.93 |
| Max. Negotiated Rate |
$20.42 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$14.04
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$12.76
|
| Rate for Payer: Aetna Government |
$12.76
|
| Rate for Payer: Brighton Health Commercial |
$19.14
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$20.42
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$17.35
|
| Rate for Payer: Group Health Inc Commercial |
$12.76
|
| Rate for Payer: Group Health Inc Medicare |
$8.93
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$12.76
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$12.76
|
|
|
TRAMADOL
|
Facility
|
OP
|
$49.93
|
|
|
Service Code
|
HCPCS 80373
|
| Hospital Charge Code |
40609881
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$39.94 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$27.46
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.01
|
| Rate for Payer: Aetna Government |
$0.01
|
| Rate for Payer: Brighton Health Commercial |
$37.45
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$39.94
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$33.95
|
| Rate for Payer: Group Health Inc Commercial |
$24.96
|
| Rate for Payer: Group Health Inc Medicare |
$17.48
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$24.96
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$24.96
|
| Rate for Payer: United Healthcare Commercial |
$19.40
|
|
|
TRAMADOL 50 MG TAB
|
Facility
|
OP
|
$0.12
|
|
| Hospital Charge Code |
41653851
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.10 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.07
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.06
|
| Rate for Payer: Aetna Government |
$0.06
|
| Rate for Payer: Brighton Health Commercial |
$0.09
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.10
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.08
|
| Rate for Payer: Group Health Inc Commercial |
$0.06
|
| Rate for Payer: Group Health Inc Medicare |
$0.04
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.06
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.06
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.08
|
|
|
TRAMADOL 50 MG TAB
|
Facility
|
OP
|
$0.12
|
|
| Hospital Charge Code |
41643851
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.10 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.07
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.06
|
| Rate for Payer: Aetna Government |
$0.06
|
| Rate for Payer: Brighton Health Commercial |
$0.09
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.10
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.08
|
| Rate for Payer: Group Health Inc Commercial |
$0.06
|
| Rate for Payer: Group Health Inc Medicare |
$0.04
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.06
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.06
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.08
|
|
|
TRAMADOL HCL 50 MG PO TABS [14632]
|
Facility
|
OP
|
$0.84
|
|
|
Service Code
|
NDC 57664037708
|
| Hospital Charge Code |
57664037708
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$0.67 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.46
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.42
|
| Rate for Payer: Aetna Government |
$0.42
|
| Rate for Payer: Brighton Health Commercial |
$0.63
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.67
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.57
|
| Rate for Payer: Group Health Inc Commercial |
$0.42
|
| Rate for Payer: Group Health Inc Medicare |
$0.29
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.42
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.42
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.54
|
|
|
TRAMADOL HCL 50 MG PO TABS [14632]
|
Facility
|
OP
|
$0.83
|
|
|
Service Code
|
NDC 65162062710
|
| Hospital Charge Code |
65162062710
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$0.67 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.46
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.42
|
| Rate for Payer: Aetna Government |
$0.42
|
| Rate for Payer: Brighton Health Commercial |
$0.63
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.67
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.57
|
| Rate for Payer: Group Health Inc Commercial |
$0.42
|
| Rate for Payer: Group Health Inc Medicare |
$0.29
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.42
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.42
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.54
|
|
|
TRAMADOL HCL 50 MG PO TABS [14632]
|
Facility
|
OP
|
$0.82
|
|
|
Service Code
|
NDC 68084080811
|
| Hospital Charge Code |
68084080811
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$0.66 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.45
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.41
|
| Rate for Payer: Aetna Government |
$0.41
|
| Rate for Payer: Brighton Health Commercial |
$0.61
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.66
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.56
|
| Rate for Payer: Group Health Inc Commercial |
$0.41
|
| Rate for Payer: Group Health Inc Medicare |
$0.29
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.41
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.41
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.53
|
|
|
TRAMADOL HCL 50 MG PO TABS [14632]
|
Facility
|
OP
|
$0.82
|
|
|
Service Code
|
NDC 68084080801
|
| Hospital Charge Code |
68084080801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$0.66 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.45
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.41
|
| Rate for Payer: Aetna Government |
$0.41
|
| Rate for Payer: Brighton Health Commercial |
$0.61
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.66
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.56
|
| Rate for Payer: Group Health Inc Commercial |
$0.41
|
| Rate for Payer: Group Health Inc Medicare |
$0.29
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.41
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.41
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.53
|
|
|
TRAMADOL HCL 50 MG PO TABS [14632]
|
Facility
|
OP
|
$0.18
|
|
|
Service Code
|
NDC 00904717961
|
| Hospital Charge Code |
00904717961
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.10
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.09
|
| Rate for Payer: Aetna Government |
$0.09
|
| Rate for Payer: Brighton Health Commercial |
$0.13
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.14
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.12
|
| Rate for Payer: Group Health Inc Commercial |
$0.09
|
| Rate for Payer: Group Health Inc Medicare |
$0.06
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.09
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.09
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.11
|
|
|
TRAMADOL + METABOLITES, URINE
|
Facility
|
OP
|
$49.93
|
|
|
Service Code
|
HCPCS 80373
|
| Hospital Charge Code |
40609023
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$39.94 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$27.46
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.01
|
| Rate for Payer: Aetna Government |
$0.01
|
| Rate for Payer: Brighton Health Commercial |
$37.45
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$39.94
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$33.95
|
| Rate for Payer: Group Health Inc Commercial |
$24.96
|
| Rate for Payer: Group Health Inc Medicare |
$17.48
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$24.96
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$24.96
|
| Rate for Payer: United Healthcare Commercial |
$19.40
|
|
|
TRAMA RESP W/CRITICAL CARE
|
Facility
|
OP
|
$2,744.13
|
|
|
Service Code
|
HCPCS G0390
|
| Hospital Charge Code |
30102509
|
|
Hospital Revenue Code
|
681
|
| Min. Negotiated Rate |
$1,108.28 |
| Max. Negotiated Rate |
$2,195.30 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,509.27
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,583.26
|
| Rate for Payer: Aetna Government |
$1,583.26
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$1,108.28
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$1,108.28
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$1,108.28
|
| Rate for Payer: Brighton Health Commercial |
$2,058.10
|
| Rate for Payer: Cash Price |
$1,583.26
|
| Rate for Payer: Cash Price |
$1,583.26
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,583.26
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2,195.30
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,866.01
|
| Rate for Payer: Elderplan Medicare Advantage |
$1,583.26
|
| Rate for Payer: EmblemHealth Commercial |
$1,583.26
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$1,345.77
|
| Rate for Payer: Fidelis Essential Plan QHP |
$1,409.10
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,583.26
|
| Rate for Payer: Fidelis Qualified Health Plan |
$1,409.10
|
| Rate for Payer: Group Health Inc Commercial |
$1,583.26
|
| Rate for Payer: Group Health Inc Medicare |
$1,583.26
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,372.06
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,583.26
|
| Rate for Payer: Healthfirst Medicare Advantage |
$1,345.77
|
| Rate for Payer: Healthfirst QHP |
$1,583.26
|
| Rate for Payer: Humana Medicare |
$1,614.93
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,583.26
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,583.26
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,583.26
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$1,266.61
|
| Rate for Payer: Wellcare Medicare |
$1,504.10
|
|
|
TRAMA RESP W/CRITICAL CARE
|
Facility
|
IP
|
$2,744.13
|
|
|
Service Code
|
HCPCS G0390
|
| Hospital Charge Code |
30102509
|
|
Hospital Revenue Code
|
681
|
| Rate for Payer: Cash Price |
$1,583.26
|
|
|
TRANEXAMIC ACID 1000 MG/10ML IV SOLN [131620]
|
Facility
|
IP
|
$0.72
|
|
|
Service Code
|
NDC 55150018810
|
| Hospital Charge Code |
55150018810
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$0.36 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.36
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.36
|
|
|
TRANEXAMIC ACID 1000 MG/10ML IV SOLN [131620]
|
Facility
|
OP
|
$0.72
|
|
|
Service Code
|
NDC 55150018810
|
| Hospital Charge Code |
55150018810
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$0.76 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.40
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.36
|
| Rate for Payer: Aetna Government |
$0.36
|
| Rate for Payer: Brighton Health Commercial |
$0.43
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.36
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.41
|
| Rate for Payer: EmblemHealth Commercial |
$0.36
|
| Rate for Payer: Fidelis Medicare Advantage |
$0.76
|
| Rate for Payer: Group Health Inc Commercial |
$0.36
|
| Rate for Payer: Group Health Inc Medicare |
$0.25
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.36
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.36
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.47
|
|
|
TRANEXAMIC ACID 1000 MG/10ML IV SOLN [131620]
|
Facility
|
IP
|
$0.66
|
|
|
Service Code
|
NDC 81284061100
|
| Hospital Charge Code |
81284061100
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$0.33 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.33
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.33
|
|
|
TRANEXAMIC ACID 1000 MG/10ML IV SOLN [131620]
|
Facility
|
IP
|
$1.38
|
|
|
Service Code
|
NDC 72485010710
|
| Hospital Charge Code |
72485010710
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$0.69 |
| Max. Negotiated Rate |
$0.69 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.69
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.69
|
|
|
TRANEXAMIC ACID 1000 MG/10ML IV SOLN [131620]
|
Facility
|
OP
|
$0.66
|
|
|
Service Code
|
NDC 81284061100
|
| Hospital Charge Code |
81284061100
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.69 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.36
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.33
|
| Rate for Payer: Aetna Government |
$0.33
|
| Rate for Payer: Brighton Health Commercial |
$0.40
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.33
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.38
|
| Rate for Payer: EmblemHealth Commercial |
$0.33
|
| Rate for Payer: Fidelis Medicare Advantage |
$0.69
|
| Rate for Payer: Group Health Inc Commercial |
$0.33
|
| Rate for Payer: Group Health Inc Medicare |
$0.23
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.33
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.33
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.43
|
|
|
TRANEXAMIC ACID 1000 MG/10ML IV SOLN [131620]
|
Facility
|
OP
|
$1.38
|
|
|
Service Code
|
NDC 72485010710
|
| Hospital Charge Code |
72485010710
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$0.48 |
| Max. Negotiated Rate |
$1.45 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.76
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.69
|
| Rate for Payer: Aetna Government |
$0.69
|
| Rate for Payer: Brighton Health Commercial |
$0.83
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.69
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.79
|
| Rate for Payer: EmblemHealth Commercial |
$0.69
|
| Rate for Payer: Fidelis Medicare Advantage |
$1.45
|
| Rate for Payer: Group Health Inc Commercial |
$0.69
|
| Rate for Payer: Group Health Inc Medicare |
$0.48
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.69
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.69
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.90
|
|
|
TRANEXAMIC ACID 100 MG/10 ML INJ
|
Facility
|
OP
|
$140.00
|
|
| Hospital Charge Code |
41646087
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$49.00 |
| Max. Negotiated Rate |
$112.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$77.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$70.00
|
| Rate for Payer: Aetna Government |
$70.00
|
| Rate for Payer: Brighton Health Commercial |
$105.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$112.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$95.20
|
| Rate for Payer: Group Health Inc Commercial |
$70.00
|
| Rate for Payer: Group Health Inc Medicare |
$49.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$70.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$70.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$91.00
|
|
