|
GLYCOSYLATED HEMOGLOBIN
|
Facility
|
OP
|
$56.00
|
|
|
Service Code
|
HCPCS 83036
|
| Hospital Charge Code |
4300385
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$9.71 |
| Max. Negotiated Rate |
$45.08 |
| Rate for Payer: Aetna of NY Commercial |
$36.40
|
| Rate for Payer: Aetna of NY Medicare |
$25.76
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$42.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$42.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$20.72
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$28.00
|
| Rate for Payer: Cash Price |
$42.00
|
| Rate for Payer: Cash Price |
$42.00
|
| Rate for Payer: CDPHP Commercial |
$45.08
|
| Rate for Payer: CDPHP Medicare |
$20.72
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$33.60
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$44.80
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$44.80
|
| Rate for Payer: EmblemHealth Medicaid |
$44.80
|
| Rate for Payer: EmblemHealth Medicare |
$19.04
|
| Rate for Payer: EmblemHealth Select Care |
$33.60
|
| Rate for Payer: Fidelis Medicare |
$21.34
|
| Rate for Payer: Galaxy Health Commercial |
$36.40
|
| Rate for Payer: Hamaspik Choice Medicare |
$20.72
|
| Rate for Payer: Humana Medicare |
$20.72
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$36.40
|
| Rate for Payer: Local 1199SEIU Medicare |
$25.76
|
| Rate for Payer: MVP Health Care of NY Commercial |
$42.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$31.53
|
| Rate for Payer: MVP Health Care of NY Medicare |
$21.76
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$42.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$9.71
|
| Rate for Payer: United Healthcare Commercial |
$42.00
|
| Rate for Payer: United Healthcare Medicare |
$20.72
|
| Rate for Payer: WellCare Medicare |
$30.80
|
|
|
GPS III APPLICATOR KIT
|
Facility
|
OP
|
$127.00
|
|
| Hospital Charge Code |
4471612
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$43.18 |
| Max. Negotiated Rate |
$102.24 |
| Rate for Payer: Aetna of NY Commercial |
$88.90
|
| Rate for Payer: Aetna of NY Medicare |
$58.42
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$95.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$95.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$46.99
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$63.50
|
| Rate for Payer: Cash Price |
$95.25
|
| Rate for Payer: CDPHP Commercial |
$102.24
|
| Rate for Payer: CDPHP Medicare |
$46.99
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$101.60
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$101.60
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$101.60
|
| Rate for Payer: EmblemHealth Medicaid |
$101.60
|
| Rate for Payer: EmblemHealth Medicare |
$43.18
|
| Rate for Payer: EmblemHealth Select Care |
$91.44
|
| Rate for Payer: Fidelis Medicare |
$48.40
|
| Rate for Payer: Galaxy Health Commercial |
$82.55
|
| Rate for Payer: Hamaspik Choice Medicare |
$46.99
|
| Rate for Payer: Humana Medicare |
$46.99
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$88.90
|
| Rate for Payer: Local 1199SEIU Medicare |
$58.42
|
| Rate for Payer: MVP Health Care of NY Commercial |
$95.25
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$71.50
|
| Rate for Payer: MVP Health Care of NY Medicare |
$49.34
|
| Rate for Payer: United Healthcare Medicare |
$46.99
|
| Rate for Payer: WellCare Medicare |
$69.85
|
|
|
GPS III APPLICATOR KIT
|
Facility
|
IP
|
$127.00
|
|
| Hospital Charge Code |
4471612
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$82.55 |
| Max. Negotiated Rate |
$82.55 |
| Rate for Payer: Cash Price |
$95.25
|
| Rate for Payer: Galaxy Health Commercial |
$82.55
|
|
|
GPS III SYSTEM
|
Facility
|
IP
|
$2,088.00
|
|
| Hospital Charge Code |
4471613
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$1,357.20 |
| Max. Negotiated Rate |
$1,357.20 |
| Rate for Payer: Cash Price |
$1,566.00
|
| Rate for Payer: Galaxy Health Commercial |
$1,357.20
|
|
|
GPS III SYSTEM
|
Facility
|
OP
|
$2,088.00
|
|
| Hospital Charge Code |
4471613
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$709.92 |
| Max. Negotiated Rate |
$1,680.84 |
| Rate for Payer: Aetna of NY Commercial |
$1,461.60
|
| Rate for Payer: Aetna of NY Medicare |
$960.48
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$1,566.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$1,566.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$772.56
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$1,044.00
|
| Rate for Payer: Cash Price |
$1,566.00
|
| Rate for Payer: CDPHP Commercial |
$1,680.84
|
| Rate for Payer: CDPHP Medicare |
$772.56
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$1,670.40
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$1,670.40
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$1,670.40
|
| Rate for Payer: EmblemHealth Medicaid |
$1,670.40
|
| Rate for Payer: EmblemHealth Medicare |
$709.92
|
| Rate for Payer: EmblemHealth Select Care |
$1,503.36
|
| Rate for Payer: Fidelis Medicare |
$795.74
|
| Rate for Payer: Galaxy Health Commercial |
$1,357.20
|
| Rate for Payer: Hamaspik Choice Medicare |
$772.56
|
| Rate for Payer: Humana Medicare |
$772.56
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,461.60
|
| Rate for Payer: Local 1199SEIU Medicare |
$960.48
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,566.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$1,175.54
|
| Rate for Payer: MVP Health Care of NY Medicare |
$811.19
|
| Rate for Payer: United Healthcare Medicare |
$772.56
|
| Rate for Payer: WellCare Medicare |
$1,148.40
|
|
|
GROSS & MICRO LAB ONLY(TISSUE PATHOLOGY)
|
Facility
|
IP
|
$155.00
|
|
|
Service Code
|
HCPCS 88305 TC
|
| Hospital Charge Code |
4301144
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$100.75 |
| Max. Negotiated Rate |
$100.75 |
| Rate for Payer: Cash Price |
$116.25
|
| Rate for Payer: Galaxy Health Commercial |
$100.75
|
|
|
GROSS & MICRO LAB ONLY(TISSUE PATHOLOGY)
|
Facility
|
OP
|
$155.00
|
|
|
Service Code
|
HCPCS 88305 TC
|
| Hospital Charge Code |
4301144
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$52.70 |
| Max. Negotiated Rate |
$124.78 |
| Rate for Payer: Aetna of NY Commercial |
$100.75
|
| Rate for Payer: Aetna of NY Medicare |
$71.30
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$116.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$116.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$57.35
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$77.50
|
| Rate for Payer: Cash Price |
$116.25
|
| Rate for Payer: CDPHP Commercial |
$124.78
|
| Rate for Payer: CDPHP Medicare |
$57.35
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$93.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$124.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$124.00
|
| Rate for Payer: EmblemHealth Medicaid |
$124.00
|
| Rate for Payer: EmblemHealth Medicare |
$52.70
|
| Rate for Payer: EmblemHealth Select Care |
$93.00
|
| Rate for Payer: Fidelis Medicare |
$59.07
|
| Rate for Payer: Galaxy Health Commercial |
$100.75
|
| Rate for Payer: Hamaspik Choice Medicare |
$57.35
|
| Rate for Payer: Humana Medicare |
$57.35
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$100.75
|
| Rate for Payer: Local 1199SEIU Medicare |
$71.30
|
| Rate for Payer: MVP Health Care of NY Commercial |
$116.25
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$87.26
|
| Rate for Payer: MVP Health Care of NY Medicare |
$60.22
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$116.25
|
| Rate for Payer: United Healthcare Commercial |
$116.25
|
| Rate for Payer: United Healthcare Medicare |
$57.35
|
| Rate for Payer: WellCare Medicare |
$85.25
|
|
|
GROUNDING PADS
|
Facility
|
IP
|
$42.00
|
|
| Hospital Charge Code |
4479217
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$27.30 |
| Max. Negotiated Rate |
$27.30 |
| Rate for Payer: Cash Price |
$31.50
|
| Rate for Payer: Galaxy Health Commercial |
$27.30
|
|
|
GROUNDING PADS
|
Facility
|
OP
|
$42.00
|
|
| Hospital Charge Code |
4479217
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$14.28 |
| Max. Negotiated Rate |
$33.81 |
| Rate for Payer: Aetna of NY Commercial |
$29.40
|
| Rate for Payer: Aetna of NY Medicare |
$19.32
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$31.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$31.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$15.54
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$21.00
|
| Rate for Payer: Cash Price |
$31.50
|
| Rate for Payer: CDPHP Commercial |
$33.81
|
| Rate for Payer: CDPHP Medicare |
$15.54
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$33.60
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$33.60
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$33.60
|
| Rate for Payer: EmblemHealth Medicaid |
$33.60
|
| Rate for Payer: EmblemHealth Medicare |
$14.28
|
| Rate for Payer: EmblemHealth Select Care |
$30.24
|
| Rate for Payer: Fidelis Medicare |
$16.01
|
| Rate for Payer: Galaxy Health Commercial |
$27.30
|
| Rate for Payer: Hamaspik Choice Medicare |
$15.54
|
| Rate for Payer: Humana Medicare |
$15.54
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$29.40
|
| Rate for Payer: Local 1199SEIU Medicare |
$19.32
|
| Rate for Payer: MVP Health Care of NY Commercial |
$31.50
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$23.65
|
| Rate for Payer: MVP Health Care of NY Medicare |
$16.32
|
| Rate for Payer: United Healthcare Medicare |
$15.54
|
| Rate for Payer: WellCare Medicare |
$23.10
|
|
|
GROUP TREATMENT THERA PROCED
|
Facility
|
OP
|
$63.00
|
|
|
Service Code
|
HCPCS 97150 GP
|
| Hospital Charge Code |
4650012
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$21.42 |
| Max. Negotiated Rate |
$179.00 |
| Rate for Payer: Aetna of NY Commercial |
$112.00
|
| Rate for Payer: Aetna of NY Medicare |
$28.98
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$47.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$47.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$23.31
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$108.00
|
| Rate for Payer: Cash Price |
$47.25
|
| Rate for Payer: Cash Price |
$47.25
|
| Rate for Payer: Cash Price |
$47.25
|
| Rate for Payer: CDPHP Commercial |
$50.72
|
| Rate for Payer: CDPHP Medicare |
$23.31
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$50.40
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$50.40
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$50.40
|
| Rate for Payer: EmblemHealth Medicaid |
$50.40
|
| Rate for Payer: EmblemHealth Medicare |
$21.42
|
| Rate for Payer: EmblemHealth Select Care |
$45.36
|
| Rate for Payer: Fidelis Medicare |
$24.01
|
| Rate for Payer: Galaxy Health Commercial |
$40.95
|
| Rate for Payer: Hamaspik Choice Medicare |
$23.31
|
| Rate for Payer: Humana Medicare |
$23.31
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$112.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$28.98
|
| Rate for Payer: MVP Health Care of NY Commercial |
$179.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$134.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$24.48
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$156.00
|
| Rate for Payer: United Healthcare Commercial |
$156.00
|
| Rate for Payer: United Healthcare Medicare |
$23.31
|
| Rate for Payer: WellCare Medicare |
$34.65
|
|
|
GROUP TREATMENT THERA PROCED
|
Facility
|
IP
|
$63.00
|
|
|
Service Code
|
HCPCS 97150 GP
|
| Hospital Charge Code |
4650012
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$40.95 |
| Max. Negotiated Rate |
$40.95 |
| Rate for Payer: Cash Price |
$47.25
|
| Rate for Payer: Galaxy Health Commercial |
$40.95
|
|
|
GROUP TREATMENT THERA PROCED (MOD 59)
|
Facility
|
OP
|
$63.00
|
|
|
Service Code
|
HCPCS 97150 GP,59
|
| Hospital Charge Code |
4650364
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$21.42 |
| Max. Negotiated Rate |
$179.00 |
| Rate for Payer: Aetna of NY Commercial |
$112.00
|
| Rate for Payer: Aetna of NY Medicare |
$28.98
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$47.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$47.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$23.31
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$108.00
|
| Rate for Payer: Cash Price |
$47.25
|
| Rate for Payer: Cash Price |
$47.25
|
| Rate for Payer: Cash Price |
$47.25
|
| Rate for Payer: CDPHP Commercial |
$50.72
|
| Rate for Payer: CDPHP Medicare |
$23.31
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$50.40
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$50.40
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$50.40
|
| Rate for Payer: EmblemHealth Medicaid |
$50.40
|
| Rate for Payer: EmblemHealth Medicare |
$21.42
|
| Rate for Payer: EmblemHealth Select Care |
$45.36
|
| Rate for Payer: Fidelis Medicare |
$24.01
|
| Rate for Payer: Galaxy Health Commercial |
$40.95
|
| Rate for Payer: Hamaspik Choice Medicare |
$23.31
|
| Rate for Payer: Humana Medicare |
$23.31
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$112.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$28.98
|
| Rate for Payer: MVP Health Care of NY Commercial |
$179.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$134.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$24.48
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$156.00
|
| Rate for Payer: United Healthcare Commercial |
$156.00
|
| Rate for Payer: United Healthcare Medicare |
$23.31
|
| Rate for Payer: WellCare Medicare |
$34.65
|
|
|
GROUP TREATMENT THERA PROCED (MOD 59)
|
Facility
|
IP
|
$63.00
|
|
|
Service Code
|
HCPCS 97150 GP,59
|
| Hospital Charge Code |
4650364
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$40.95 |
| Max. Negotiated Rate |
$40.95 |
| Rate for Payer: Cash Price |
$47.25
|
| Rate for Payer: Galaxy Health Commercial |
$40.95
|
|
|
GROUP TREATMENT THERA PROCED (MOD 59 W KX)
|
Facility
|
IP
|
$63.00
|
|
|
Service Code
|
HCPCS 97150 GP,59,KX
|
| Hospital Charge Code |
4650416
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$40.95 |
| Max. Negotiated Rate |
$40.95 |
| Rate for Payer: Cash Price |
$47.25
|
| Rate for Payer: Galaxy Health Commercial |
$40.95
|
|
|
GROUP TREATMENT THERA PROCED (MOD 59 W KX)
|
Facility
|
OP
|
$63.00
|
|
|
Service Code
|
HCPCS 97150 GP,59,KX
|
| Hospital Charge Code |
4650416
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$21.42 |
| Max. Negotiated Rate |
$179.00 |
| Rate for Payer: Aetna of NY Commercial |
$112.00
|
| Rate for Payer: Aetna of NY Medicare |
$28.98
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$47.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$47.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$23.31
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$108.00
|
| Rate for Payer: Cash Price |
$47.25
|
| Rate for Payer: Cash Price |
$47.25
|
| Rate for Payer: Cash Price |
$47.25
|
| Rate for Payer: CDPHP Commercial |
$50.72
|
| Rate for Payer: CDPHP Medicare |
$23.31
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$50.40
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$50.40
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$50.40
|
| Rate for Payer: EmblemHealth Medicaid |
$50.40
|
| Rate for Payer: EmblemHealth Medicare |
$21.42
|
| Rate for Payer: EmblemHealth Select Care |
$45.36
|
| Rate for Payer: Fidelis Medicare |
$24.01
|
| Rate for Payer: Galaxy Health Commercial |
$40.95
|
| Rate for Payer: Hamaspik Choice Medicare |
$23.31
|
| Rate for Payer: Humana Medicare |
$23.31
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$112.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$28.98
|
| Rate for Payer: MVP Health Care of NY Commercial |
$179.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$134.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$24.48
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$156.00
|
| Rate for Payer: United Healthcare Commercial |
$156.00
|
| Rate for Payer: United Healthcare Medicare |
$23.31
|
| Rate for Payer: WellCare Medicare |
$34.65
|
|
|
GROUP TREATMENT THERA PROCED (W/ KX)
|
Facility
|
IP
|
$63.00
|
|
|
Service Code
|
HCPCS 97150 GP,KX
|
| Hospital Charge Code |
4650309
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$40.95 |
| Max. Negotiated Rate |
$40.95 |
| Rate for Payer: Cash Price |
$47.25
|
| Rate for Payer: Galaxy Health Commercial |
$40.95
|
|
|
GROUP TREATMENT THERA PROCED (W/ KX)
|
Facility
|
OP
|
$63.00
|
|
|
Service Code
|
HCPCS 97150 GP,KX
|
| Hospital Charge Code |
4650309
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$21.42 |
| Max. Negotiated Rate |
$179.00 |
| Rate for Payer: Aetna of NY Commercial |
$112.00
|
| Rate for Payer: Aetna of NY Medicare |
$28.98
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$47.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$47.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$23.31
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$108.00
|
| Rate for Payer: Cash Price |
$47.25
|
| Rate for Payer: Cash Price |
$47.25
|
| Rate for Payer: Cash Price |
$47.25
|
| Rate for Payer: CDPHP Commercial |
$50.72
|
| Rate for Payer: CDPHP Medicare |
$23.31
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$50.40
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$50.40
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$50.40
|
| Rate for Payer: EmblemHealth Medicaid |
$50.40
|
| Rate for Payer: EmblemHealth Medicare |
$21.42
|
| Rate for Payer: EmblemHealth Select Care |
$45.36
|
| Rate for Payer: Fidelis Medicare |
$24.01
|
| Rate for Payer: Galaxy Health Commercial |
$40.95
|
| Rate for Payer: Hamaspik Choice Medicare |
$23.31
|
| Rate for Payer: Humana Medicare |
$23.31
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$112.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$28.98
|
| Rate for Payer: MVP Health Care of NY Commercial |
$179.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$134.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$24.48
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$156.00
|
| Rate for Payer: United Healthcare Commercial |
$156.00
|
| Rate for Payer: United Healthcare Medicare |
$23.31
|
| Rate for Payer: WellCare Medicare |
$34.65
|
|
|
GUAIFEN/COD 100-10MG/5ML SYRP 100X5ML
|
Facility
|
OP
|
$6.18
|
|
|
Service Code
|
NDC 00121177505
|
| Hospital Charge Code |
4400338
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.10 |
| Max. Negotiated Rate |
$4.97 |
| Rate for Payer: Aetna of NY Commercial |
$4.33
|
| Rate for Payer: Aetna of NY Medicare |
$2.84
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$4.64
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$4.64
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$2.29
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$3.09
|
| Rate for Payer: Cash Price |
$4.64
|
| Rate for Payer: CDPHP Commercial |
$4.97
|
| Rate for Payer: CDPHP Medicare |
$2.29
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$4.94
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$4.94
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$4.94
|
| Rate for Payer: EmblemHealth Medicaid |
$4.94
|
| Rate for Payer: EmblemHealth Medicare |
$2.10
|
| Rate for Payer: EmblemHealth Select Care |
$4.45
|
| Rate for Payer: Fidelis Medicare |
$2.36
|
| Rate for Payer: Galaxy Health Commercial |
$4.02
|
| Rate for Payer: Hamaspik Choice Medicare |
$2.29
|
| Rate for Payer: Humana Medicare |
$2.29
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$4.33
|
| Rate for Payer: Local 1199SEIU Medicare |
$2.84
|
| Rate for Payer: MVP Health Care of NY Commercial |
$4.64
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$3.48
|
| Rate for Payer: MVP Health Care of NY Medicare |
$2.40
|
| Rate for Payer: United Healthcare Medicare |
$2.29
|
| Rate for Payer: WellCare Medicare |
$3.40
|
|
|
GUAIFEN/COD 100-10MG/5ML SYRP 100X5ML
|
Facility
|
IP
|
$6.18
|
|
|
Service Code
|
NDC 00121177505
|
| Hospital Charge Code |
4400338
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.40 |
| Max. Negotiated Rate |
$4.02 |
| Rate for Payer: Cash Price |
$4.64
|
| Rate for Payer: Galaxy Health Commercial |
$4.02
|
| Rate for Payer: WellCare Medicare |
$3.40
|
|
|
GUAIFEN/DM 100-10MG/5ML SYRP 100X10ML
|
Facility
|
IP
|
$6.18
|
|
|
Service Code
|
NDC 00121127610
|
| Hospital Charge Code |
4400337
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.40 |
| Max. Negotiated Rate |
$4.02 |
| Rate for Payer: Cash Price |
$4.64
|
| Rate for Payer: Galaxy Health Commercial |
$4.02
|
| Rate for Payer: WellCare Medicare |
$3.40
|
|
|
GUAIFEN/DM 100-10MG/5ML SYRP 100X10ML
|
Facility
|
OP
|
$6.18
|
|
|
Service Code
|
NDC 00121127610
|
| Hospital Charge Code |
4400337
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.10 |
| Max. Negotiated Rate |
$4.97 |
| Rate for Payer: Aetna of NY Commercial |
$4.33
|
| Rate for Payer: Aetna of NY Medicare |
$2.84
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$4.64
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$4.64
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$2.29
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$3.09
|
| Rate for Payer: Cash Price |
$4.64
|
| Rate for Payer: CDPHP Commercial |
$4.97
|
| Rate for Payer: CDPHP Medicare |
$2.29
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$4.94
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$4.94
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$4.94
|
| Rate for Payer: EmblemHealth Medicaid |
$4.94
|
| Rate for Payer: EmblemHealth Medicare |
$2.10
|
| Rate for Payer: EmblemHealth Select Care |
$4.45
|
| Rate for Payer: Fidelis Medicare |
$2.36
|
| Rate for Payer: Galaxy Health Commercial |
$4.02
|
| Rate for Payer: Hamaspik Choice Medicare |
$2.29
|
| Rate for Payer: Humana Medicare |
$2.29
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$4.33
|
| Rate for Payer: Local 1199SEIU Medicare |
$2.84
|
| Rate for Payer: MVP Health Care of NY Commercial |
$4.64
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$3.48
|
| Rate for Payer: MVP Health Care of NY Medicare |
$2.40
|
| Rate for Payer: United Healthcare Medicare |
$2.29
|
| Rate for Payer: WellCare Medicare |
$3.40
|
|
|
GUAIFENESIN 100MG/5ML SYRP 100X10ML
|
Facility
|
OP
|
$6.18
|
|
|
Service Code
|
NDC 00121174410
|
| Hospital Charge Code |
4400336
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.10 |
| Max. Negotiated Rate |
$4.97 |
| Rate for Payer: Aetna of NY Commercial |
$4.33
|
| Rate for Payer: Aetna of NY Medicare |
$2.84
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$4.64
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$4.64
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$2.29
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$3.09
|
| Rate for Payer: Cash Price |
$4.64
|
| Rate for Payer: CDPHP Commercial |
$4.97
|
| Rate for Payer: CDPHP Medicare |
$2.29
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$4.94
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$4.94
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$4.94
|
| Rate for Payer: EmblemHealth Medicaid |
$4.94
|
| Rate for Payer: EmblemHealth Medicare |
$2.10
|
| Rate for Payer: EmblemHealth Select Care |
$4.45
|
| Rate for Payer: Fidelis Medicare |
$2.36
|
| Rate for Payer: Galaxy Health Commercial |
$4.02
|
| Rate for Payer: Hamaspik Choice Medicare |
$2.29
|
| Rate for Payer: Humana Medicare |
$2.29
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$4.33
|
| Rate for Payer: Local 1199SEIU Medicare |
$2.84
|
| Rate for Payer: MVP Health Care of NY Commercial |
$4.64
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$3.48
|
| Rate for Payer: MVP Health Care of NY Medicare |
$2.40
|
| Rate for Payer: United Healthcare Medicare |
$2.29
|
| Rate for Payer: WellCare Medicare |
$3.40
|
|
|
GUAIFENESIN 100MG/5ML SYRP 100X10ML
|
Facility
|
IP
|
$6.18
|
|
|
Service Code
|
NDC 00121174410
|
| Hospital Charge Code |
4400336
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.40 |
| Max. Negotiated Rate |
$4.02 |
| Rate for Payer: Cash Price |
$4.64
|
| Rate for Payer: Galaxy Health Commercial |
$4.02
|
| Rate for Payer: WellCare Medicare |
$3.40
|
|
|
GUAIFENESIN 600MG TABS 100 EA
|
Facility
|
OP
|
$6.18
|
|
|
Service Code
|
NDC 63824000815
|
| Hospital Charge Code |
4400529
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.10 |
| Max. Negotiated Rate |
$4.97 |
| Rate for Payer: Aetna of NY Commercial |
$4.33
|
| Rate for Payer: Aetna of NY Medicare |
$2.84
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$4.64
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$4.64
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$2.29
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$3.09
|
| Rate for Payer: Cash Price |
$4.64
|
| Rate for Payer: CDPHP Commercial |
$4.97
|
| Rate for Payer: CDPHP Medicare |
$2.29
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$4.94
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$4.94
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$4.94
|
| Rate for Payer: EmblemHealth Medicaid |
$4.94
|
| Rate for Payer: EmblemHealth Medicare |
$2.10
|
| Rate for Payer: EmblemHealth Select Care |
$4.45
|
| Rate for Payer: Fidelis Medicare |
$2.36
|
| Rate for Payer: Galaxy Health Commercial |
$4.02
|
| Rate for Payer: Hamaspik Choice Medicare |
$2.29
|
| Rate for Payer: Humana Medicare |
$2.29
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$4.33
|
| Rate for Payer: Local 1199SEIU Medicare |
$2.84
|
| Rate for Payer: MVP Health Care of NY Commercial |
$4.64
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$3.48
|
| Rate for Payer: MVP Health Care of NY Medicare |
$2.40
|
| Rate for Payer: United Healthcare Medicare |
$2.29
|
| Rate for Payer: WellCare Medicare |
$3.40
|
|
|
GUAIFENESIN 600MG TABS 100 EA
|
Facility
|
IP
|
$6.18
|
|
|
Service Code
|
NDC 63824000815
|
| Hospital Charge Code |
4400529
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.40 |
| Max. Negotiated Rate |
$4.02 |
| Rate for Payer: Cash Price |
$4.64
|
| Rate for Payer: Galaxy Health Commercial |
$4.02
|
| Rate for Payer: WellCare Medicare |
$3.40
|
|
