|
STRESS TTE ONLY
|
Facility
OP
|
$1,579.00
|
|
|
Service Code
|
HCPCS 93350
|
| Hospital Charge Code |
4480010
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$121.20 |
| Max. Negotiated Rate |
$1,271.10 |
| Rate for Payer: Aetna of NY Commercial |
$1,026.35
|
| Rate for Payer: Aetna of NY Medicare |
$726.34
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$1,184.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$1,184.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$584.23
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$789.50
|
| Rate for Payer: Cash Price |
$1,184.25
|
| Rate for Payer: Cash Price |
$1,184.25
|
| Rate for Payer: CDPHP Commercial |
$1,271.10
|
| Rate for Payer: CDPHP Medicare |
$584.23
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$1,263.20
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$1,263.20
|
| Rate for Payer: EmblemHealth Medicaid |
$1,263.20
|
| Rate for Payer: EmblemHealth Medicare |
$536.86
|
| Rate for Payer: Fidelis Medicare |
$601.76
|
| Rate for Payer: Galaxy Health Commercial |
$1,026.35
|
| Rate for Payer: Hamaspik Choice Medicare |
$584.23
|
| Rate for Payer: Humana Medicare |
$584.23
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,026.35
|
| Rate for Payer: Local 1199SEIU Medicare |
$726.34
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,184.25
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$888.98
|
| Rate for Payer: MVP Health Care of NY Medicare |
$613.44
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$1,184.25
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$121.20
|
| Rate for Payer: United Healthcare Commercial |
$1,184.25
|
| Rate for Payer: United Healthcare Medicare |
$584.23
|
| Rate for Payer: WellCare Medicare |
$868.45
|
|
|
STRIP IODOFORM PAC 1/2X5YD
|
Facility
OP
|
$13.00
|
|
| Hospital Charge Code |
4471650
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$4.42 |
| Max. Negotiated Rate |
$10.46 |
| Rate for Payer: Aetna of NY Commercial |
$9.10
|
| Rate for Payer: Aetna of NY Medicare |
$5.98
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$9.75
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$9.75
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$4.81
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$6.50
|
| Rate for Payer: Cash Price |
$9.75
|
| Rate for Payer: CDPHP Commercial |
$10.46
|
| Rate for Payer: CDPHP Medicare |
$4.81
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$10.40
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$10.40
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$10.40
|
| Rate for Payer: EmblemHealth Medicaid |
$10.40
|
| Rate for Payer: EmblemHealth Medicare |
$4.42
|
| Rate for Payer: EmblemHealth Select Care |
$9.36
|
| Rate for Payer: Fidelis Medicare |
$4.95
|
| Rate for Payer: Galaxy Health Commercial |
$8.45
|
| Rate for Payer: Hamaspik Choice Medicare |
$4.81
|
| Rate for Payer: Humana Medicare |
$4.81
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$9.10
|
| Rate for Payer: Local 1199SEIU Medicare |
$5.98
|
| Rate for Payer: MVP Health Care of NY Commercial |
$9.75
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$7.32
|
| Rate for Payer: MVP Health Care of NY Medicare |
$5.05
|
| Rate for Payer: United Healthcare Medicare |
$4.81
|
| Rate for Payer: WellCare Medicare |
$7.15
|
|
|
STRIP IODOFORM PAC 1/4X5YD
|
Facility
OP
|
$11.00
|
|
| Hospital Charge Code |
4471649
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$3.74 |
| Max. Negotiated Rate |
$8.86 |
| Rate for Payer: Aetna of NY Commercial |
$7.70
|
| Rate for Payer: Aetna of NY Medicare |
$5.06
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$8.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$8.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$4.07
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$5.50
|
| Rate for Payer: Cash Price |
$8.25
|
| Rate for Payer: CDPHP Commercial |
$8.86
|
| Rate for Payer: CDPHP Medicare |
$4.07
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$8.80
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$8.80
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$8.80
|
| Rate for Payer: EmblemHealth Medicaid |
$8.80
|
| Rate for Payer: EmblemHealth Medicare |
$3.74
|
| Rate for Payer: EmblemHealth Select Care |
$7.92
|
| Rate for Payer: Fidelis Medicare |
$4.19
|
| Rate for Payer: Galaxy Health Commercial |
$7.15
|
| Rate for Payer: Hamaspik Choice Medicare |
$4.07
|
| Rate for Payer: Humana Medicare |
$4.07
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$7.70
|
| Rate for Payer: Local 1199SEIU Medicare |
$5.06
|
| Rate for Payer: MVP Health Care of NY Commercial |
$8.25
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$6.19
|
| Rate for Payer: MVP Health Care of NY Medicare |
$4.27
|
| Rate for Payer: United Healthcare Medicare |
$4.07
|
| Rate for Payer: WellCare Medicare |
$6.05
|
|
|
STRIP IODOFORM PAC 1"X5YD
|
Facility
OP
|
$14.00
|
|
| Hospital Charge Code |
4471651
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$4.76 |
| Max. Negotiated Rate |
$11.27 |
| Rate for Payer: Aetna of NY Commercial |
$9.80
|
| Rate for Payer: Aetna of NY Medicare |
$6.44
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$10.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$10.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$5.18
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$7.00
|
| Rate for Payer: Cash Price |
$10.50
|
| Rate for Payer: CDPHP Commercial |
$11.27
|
| Rate for Payer: CDPHP Medicare |
$5.18
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$11.20
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$11.20
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$11.20
|
| Rate for Payer: EmblemHealth Medicaid |
$11.20
|
| Rate for Payer: EmblemHealth Medicare |
$4.76
|
| Rate for Payer: EmblemHealth Select Care |
$10.08
|
| Rate for Payer: Fidelis Medicare |
$5.34
|
| Rate for Payer: Galaxy Health Commercial |
$9.10
|
| Rate for Payer: Hamaspik Choice Medicare |
$5.18
|
| Rate for Payer: Humana Medicare |
$5.18
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$9.80
|
| Rate for Payer: Local 1199SEIU Medicare |
$6.44
|
| Rate for Payer: MVP Health Care of NY Commercial |
$10.50
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$7.88
|
| Rate for Payer: MVP Health Care of NY Medicare |
$5.44
|
| Rate for Payer: United Healthcare Medicare |
$5.18
|
| Rate for Payer: WellCare Medicare |
$7.70
|
|
|
STRIP IODOFORM PAC 2"X5YD
|
Facility
OP
|
$19.00
|
|
| Hospital Charge Code |
4471652
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$6.46 |
| Max. Negotiated Rate |
$15.30 |
| Rate for Payer: Aetna of NY Commercial |
$13.30
|
| Rate for Payer: Aetna of NY Medicare |
$8.74
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$14.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$14.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$7.03
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$9.50
|
| Rate for Payer: Cash Price |
$14.25
|
| Rate for Payer: CDPHP Commercial |
$15.30
|
| Rate for Payer: CDPHP Medicare |
$7.03
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$15.20
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$15.20
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$15.20
|
| Rate for Payer: EmblemHealth Medicaid |
$15.20
|
| Rate for Payer: EmblemHealth Medicare |
$6.46
|
| Rate for Payer: EmblemHealth Select Care |
$13.68
|
| Rate for Payer: Fidelis Medicare |
$7.24
|
| Rate for Payer: Galaxy Health Commercial |
$12.35
|
| Rate for Payer: Hamaspik Choice Medicare |
$7.03
|
| Rate for Payer: Humana Medicare |
$7.03
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$13.30
|
| Rate for Payer: Local 1199SEIU Medicare |
$8.74
|
| Rate for Payer: MVP Health Care of NY Commercial |
$14.25
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$10.70
|
| Rate for Payer: MVP Health Care of NY Medicare |
$7.38
|
| Rate for Payer: United Healthcare Medicare |
$7.03
|
| Rate for Payer: WellCare Medicare |
$10.45
|
|
|
STRYKEFLOW II W/ TIP SUC/IRR
|
Facility
OP
|
$330.00
|
|
| Hospital Charge Code |
4471233
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$112.20 |
| Max. Negotiated Rate |
$265.65 |
| Rate for Payer: Aetna of NY Commercial |
$231.00
|
| Rate for Payer: Aetna of NY Medicare |
$151.80
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$247.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$247.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$122.10
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$165.00
|
| Rate for Payer: Cash Price |
$247.50
|
| Rate for Payer: CDPHP Commercial |
$265.65
|
| Rate for Payer: CDPHP Medicare |
$122.10
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$264.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$264.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$264.00
|
| Rate for Payer: EmblemHealth Medicaid |
$264.00
|
| Rate for Payer: EmblemHealth Medicare |
$112.20
|
| Rate for Payer: EmblemHealth Select Care |
$237.60
|
| Rate for Payer: Fidelis Medicare |
$125.76
|
| Rate for Payer: Galaxy Health Commercial |
$214.50
|
| Rate for Payer: Hamaspik Choice Medicare |
$122.10
|
| Rate for Payer: Humana Medicare |
$122.10
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$231.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$151.80
|
| Rate for Payer: MVP Health Care of NY Commercial |
$247.50
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$185.79
|
| Rate for Payer: MVP Health Care of NY Medicare |
$128.20
|
| Rate for Payer: United Healthcare Medicare |
$122.10
|
| Rate for Payer: WellCare Medicare |
$181.50
|
|
|
STRYKER BATTERY PACK 9.6V
|
Facility
OP
|
$1,504.00
|
|
| Hospital Charge Code |
4471353
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$511.36 |
| Max. Negotiated Rate |
$1,210.72 |
| Rate for Payer: Aetna of NY Commercial |
$1,052.80
|
| Rate for Payer: Aetna of NY Medicare |
$691.84
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$1,128.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$1,128.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$556.48
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$752.00
|
| Rate for Payer: Cash Price |
$1,128.00
|
| Rate for Payer: CDPHP Commercial |
$1,210.72
|
| Rate for Payer: CDPHP Medicare |
$556.48
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$1,203.20
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$1,203.20
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$1,203.20
|
| Rate for Payer: EmblemHealth Medicaid |
$1,203.20
|
| Rate for Payer: EmblemHealth Medicare |
$511.36
|
| Rate for Payer: EmblemHealth Select Care |
$1,082.88
|
| Rate for Payer: Fidelis Medicare |
$573.17
|
| Rate for Payer: Galaxy Health Commercial |
$977.60
|
| Rate for Payer: Hamaspik Choice Medicare |
$556.48
|
| Rate for Payer: Humana Medicare |
$556.48
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,052.80
|
| Rate for Payer: Local 1199SEIU Medicare |
$691.84
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,128.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$846.75
|
| Rate for Payer: MVP Health Care of NY Medicare |
$584.30
|
| Rate for Payer: United Healthcare Medicare |
$556.48
|
| Rate for Payer: WellCare Medicare |
$827.20
|
|
|
STRYKER CUTTING BLADE
|
Facility
OP
|
$110.00
|
|
| Hospital Charge Code |
4479160
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$37.40 |
| Max. Negotiated Rate |
$88.55 |
| Rate for Payer: Aetna of NY Commercial |
$77.00
|
| Rate for Payer: Aetna of NY Medicare |
$50.60
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$82.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$82.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$40.70
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$55.00
|
| Rate for Payer: Cash Price |
$82.50
|
| Rate for Payer: CDPHP Commercial |
$88.55
|
| Rate for Payer: CDPHP Medicare |
$40.70
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$88.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$88.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$88.00
|
| Rate for Payer: EmblemHealth Medicaid |
$88.00
|
| Rate for Payer: EmblemHealth Medicare |
$37.40
|
| Rate for Payer: EmblemHealth Select Care |
$79.20
|
| Rate for Payer: Fidelis Medicare |
$41.92
|
| Rate for Payer: Galaxy Health Commercial |
$71.50
|
| Rate for Payer: Hamaspik Choice Medicare |
$40.70
|
| Rate for Payer: Humana Medicare |
$40.70
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$77.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$50.60
|
| Rate for Payer: MVP Health Care of NY Commercial |
$82.50
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$61.93
|
| Rate for Payer: MVP Health Care of NY Medicare |
$42.74
|
| Rate for Payer: United Healthcare Medicare |
$40.70
|
| Rate for Payer: WellCare Medicare |
$60.50
|
|
|
SUBOXONE 12 MG-3 MG SL FILM 1 ea, 30 eaches
|
Facility
OP
|
$60.00
|
|
|
Service Code
|
HCPCS J0575
|
| Hospital Charge Code |
4401342
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.39 |
| Max. Negotiated Rate |
$48.30 |
| Rate for Payer: Aetna of NY Commercial |
$33.00
|
| Rate for Payer: Aetna of NY Medicare |
$27.60
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$27.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$27.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$22.20
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$30.00
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: CDPHP Commercial |
$48.30
|
| Rate for Payer: CDPHP Medicare |
$22.20
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$48.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$48.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$48.00
|
| Rate for Payer: EmblemHealth Medicaid |
$48.00
|
| Rate for Payer: EmblemHealth Medicare |
$20.40
|
| Rate for Payer: EmblemHealth Select Care |
$43.20
|
| Rate for Payer: Fidelis Medicare |
$22.87
|
| Rate for Payer: Galaxy Health Commercial |
$39.00
|
| Rate for Payer: Hamaspik Choice Medicare |
$22.20
|
| Rate for Payer: Humana Medicare |
$22.20
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$33.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$27.60
|
| Rate for Payer: MVP Health Care of NY Commercial |
$45.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$33.78
|
| Rate for Payer: MVP Health Care of NY Medicare |
$23.31
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$30.18
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$18.39
|
| Rate for Payer: United Healthcare Commercial |
$30.18
|
| Rate for Payer: United Healthcare Medicare |
$22.20
|
| Rate for Payer: WellCare Medicare |
$33.00
|
|
|
SUBOXONE 2 MG-0.5 MG SL FILM 1 ea, 30 eaches
|
Facility
OP
|
$17.00
|
|
|
Service Code
|
HCPCS J0574
|
| Hospital Charge Code |
4401338
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.78 |
| Max. Negotiated Rate |
$708.00 |
| Rate for Payer: Aetna of NY Commercial |
$9.35
|
| Rate for Payer: Aetna of NY Medicare |
$7.82
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$7.65
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$7.65
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Essential Plan |
$15.93
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicaid |
$7.08
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$6.29
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$8.50
|
| Rate for Payer: Cash Price |
$12.75
|
| Rate for Payer: Cash Price |
$12.75
|
| Rate for Payer: CDPHP Child Health Plus/HARP/Select Plan |
$7.08
|
| Rate for Payer: CDPHP Commercial |
$13.68
|
| Rate for Payer: CDPHP Essential Plan |
$15.93
|
| Rate for Payer: CDPHP Medicare |
$6.29
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$13.60
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$8.50
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$7.08
|
| Rate for Payer: EmblemHealth Medicaid |
$7.08
|
| Rate for Payer: EmblemHealth Medicare |
$5.78
|
| Rate for Payer: EmblemHealth Select Care |
$12.24
|
| Rate for Payer: Fidelis Child Health Plus/Essential Plan/HARP/Medicaid |
$15.93
|
| Rate for Payer: Fidelis Medicare |
$6.48
|
| Rate for Payer: Galaxy Health Commercial |
$11.05
|
| Rate for Payer: Galaxy Health Workers Comp |
$6.94
|
| Rate for Payer: Hamaspik Choice Medicaid |
$708.00
|
| Rate for Payer: Hamaspik Choice Medicare |
$6.29
|
| Rate for Payer: Humana Medicare |
$6.29
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$9.35
|
| Rate for Payer: Local 1199SEIU Medicare |
$7.82
|
| Rate for Payer: MVP Health Care of NY Child Health Plus/Family Health Plus/HARP/Medicaid |
$708.00
|
| Rate for Payer: MVP Health Care of NY Commercial |
$12.75
|
| Rate for Payer: MVP Health Care of NY Essential Plan 1&2 |
$15.22
|
| Rate for Payer: MVP Health Care of NY Essential Plan 3&4 |
$15.22
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$9.57
|
| Rate for Payer: MVP Health Care of NY Medicare |
$6.60
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$19.32
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$7.08
|
| Rate for Payer: United Healthcare Commercial |
$19.32
|
| Rate for Payer: United Healthcare Medicare |
$6.29
|
| Rate for Payer: WellCare Child Health Plus/Family Health Plus/Medicaid |
$7.43
|
| Rate for Payer: WellCare Medicare |
$9.35
|
|
|
SUBOXONE 4 MG-1 MG SL FILM 1 ea, 30 eaches
|
Facility
OP
|
$30.00
|
|
|
Service Code
|
HCPCS J0573
|
| Hospital Charge Code |
4401341
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.91 |
| Max. Negotiated Rate |
$501.00 |
| Rate for Payer: Aetna of NY Commercial |
$16.50
|
| Rate for Payer: Aetna of NY Medicare |
$13.80
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$13.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$13.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Essential Plan |
$11.27
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicaid |
$5.01
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$11.10
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$15.00
|
| Rate for Payer: Cash Price |
$22.50
|
| Rate for Payer: Cash Price |
$22.50
|
| Rate for Payer: CDPHP Child Health Plus/HARP/Select Plan |
$5.01
|
| Rate for Payer: CDPHP Commercial |
$24.15
|
| Rate for Payer: CDPHP Essential Plan |
$11.27
|
| Rate for Payer: CDPHP Medicare |
$11.10
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$24.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$6.01
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$5.01
|
| Rate for Payer: EmblemHealth Medicaid |
$5.01
|
| Rate for Payer: EmblemHealth Medicare |
$10.20
|
| Rate for Payer: EmblemHealth Select Care |
$21.60
|
| Rate for Payer: Fidelis Child Health Plus/Essential Plan/HARP/Medicaid |
$11.27
|
| Rate for Payer: Fidelis Medicare |
$11.43
|
| Rate for Payer: Galaxy Health Commercial |
$19.50
|
| Rate for Payer: Galaxy Health Workers Comp |
$4.91
|
| Rate for Payer: Hamaspik Choice Medicaid |
$501.00
|
| Rate for Payer: Hamaspik Choice Medicare |
$11.10
|
| Rate for Payer: Humana Medicare |
$11.10
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$16.50
|
| Rate for Payer: Local 1199SEIU Medicare |
$13.80
|
| Rate for Payer: MVP Health Care of NY Child Health Plus/Family Health Plus/HARP/Medicaid |
$501.00
|
| Rate for Payer: MVP Health Care of NY Commercial |
$22.50
|
| Rate for Payer: MVP Health Care of NY Essential Plan 1&2 |
$10.77
|
| Rate for Payer: MVP Health Care of NY Essential Plan 3&4 |
$10.77
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$16.89
|
| Rate for Payer: MVP Health Care of NY Medicare |
$11.66
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$18.63
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$5.01
|
| Rate for Payer: United Healthcare Commercial |
$18.63
|
| Rate for Payer: United Healthcare Medicare |
$11.10
|
| Rate for Payer: WellCare Child Health Plus/Family Health Plus/Medicaid |
$5.26
|
| Rate for Payer: WellCare Medicare |
$16.50
|
|
|
SUBOXONE 8 MG-2 MG SL FILM 1 ea, 30 eaches
|
Facility
OP
|
$30.00
|
|
|
Service Code
|
HCPCS J0574
|
| Hospital Charge Code |
4401337
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.94 |
| Max. Negotiated Rate |
$708.00 |
| Rate for Payer: Aetna of NY Commercial |
$16.50
|
| Rate for Payer: Aetna of NY Medicare |
$13.80
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$13.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$13.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Essential Plan |
$15.93
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicaid |
$7.08
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$11.10
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$15.00
|
| Rate for Payer: Cash Price |
$22.50
|
| Rate for Payer: Cash Price |
$22.50
|
| Rate for Payer: CDPHP Child Health Plus/HARP/Select Plan |
$7.08
|
| Rate for Payer: CDPHP Commercial |
$24.15
|
| Rate for Payer: CDPHP Essential Plan |
$15.93
|
| Rate for Payer: CDPHP Medicare |
$11.10
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$24.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$8.50
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$7.08
|
| Rate for Payer: EmblemHealth Medicaid |
$7.08
|
| Rate for Payer: EmblemHealth Medicare |
$10.20
|
| Rate for Payer: EmblemHealth Select Care |
$21.60
|
| Rate for Payer: Fidelis Child Health Plus/Essential Plan/HARP/Medicaid |
$15.93
|
| Rate for Payer: Fidelis Medicare |
$11.43
|
| Rate for Payer: Galaxy Health Commercial |
$19.50
|
| Rate for Payer: Galaxy Health Workers Comp |
$6.94
|
| Rate for Payer: Hamaspik Choice Medicaid |
$708.00
|
| Rate for Payer: Hamaspik Choice Medicare |
$11.10
|
| Rate for Payer: Humana Medicare |
$11.10
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$16.50
|
| Rate for Payer: Local 1199SEIU Medicare |
$13.80
|
| Rate for Payer: MVP Health Care of NY Child Health Plus/Family Health Plus/HARP/Medicaid |
$708.00
|
| Rate for Payer: MVP Health Care of NY Commercial |
$22.50
|
| Rate for Payer: MVP Health Care of NY Essential Plan 1&2 |
$15.22
|
| Rate for Payer: MVP Health Care of NY Essential Plan 3&4 |
$15.22
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$16.89
|
| Rate for Payer: MVP Health Care of NY Medicare |
$11.66
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$19.32
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$7.08
|
| Rate for Payer: United Healthcare Commercial |
$19.32
|
| Rate for Payer: United Healthcare Medicare |
$11.10
|
| Rate for Payer: WellCare Child Health Plus/Family Health Plus/Medicaid |
$7.43
|
| Rate for Payer: WellCare Medicare |
$16.50
|
|
|
SUCCINYLCHOLINE CHLORIDE, UP TO 20 MG
|
Facility
OP
|
$6.91
|
|
|
Service Code
|
HCPCS J0330
|
| Hospital Charge Code |
4400675
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.72 |
| Max. Negotiated Rate |
$5.56 |
| Rate for Payer: Aetna of NY Commercial |
$3.80
|
| Rate for Payer: Aetna of NY Medicare |
$3.18
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$3.11
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$3.11
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$2.56
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$3.46
|
| Rate for Payer: Cash Price |
$5.18
|
| Rate for Payer: Cash Price |
$5.18
|
| Rate for Payer: CDPHP Commercial |
$5.56
|
| Rate for Payer: CDPHP Medicare |
$2.56
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$5.53
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$5.53
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$5.53
|
| Rate for Payer: EmblemHealth Medicaid |
$5.53
|
| Rate for Payer: EmblemHealth Medicare |
$2.35
|
| Rate for Payer: EmblemHealth Select Care |
$4.98
|
| Rate for Payer: Fidelis Medicare |
$2.63
|
| Rate for Payer: Galaxy Health Commercial |
$4.49
|
| Rate for Payer: Hamaspik Choice Medicare |
$2.56
|
| Rate for Payer: Humana Medicare |
$2.56
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$3.80
|
| Rate for Payer: Local 1199SEIU Medicare |
$3.18
|
| Rate for Payer: MVP Health Care of NY Commercial |
$5.18
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$3.89
|
| Rate for Payer: MVP Health Care of NY Medicare |
$2.68
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$2.87
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$1.72
|
| Rate for Payer: United Healthcare Commercial |
$2.87
|
| Rate for Payer: United Healthcare Medicare |
$2.56
|
| Rate for Payer: WellCare Medicare |
$3.80
|
|
|
SUCRALFATE 1GM TABS 10X10EA
|
Facility
OP
|
$6.18
|
|
| Hospital Charge Code |
4400724
|
|
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
|
|
|
SUCRALFATE SUSP
|
Facility
OP
|
$24.21
|
|
| Hospital Charge Code |
4408976
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.23 |
| Max. Negotiated Rate |
$19.49 |
| Rate for Payer: Aetna of NY Commercial |
$16.95
|
| Rate for Payer: Aetna of NY Medicare |
$11.14
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$18.16
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$18.16
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$8.96
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$12.10
|
| Rate for Payer: Cash Price |
$18.16
|
| Rate for Payer: CDPHP Commercial |
$19.49
|
| Rate for Payer: CDPHP Medicare |
$8.96
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$19.37
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$19.37
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$19.37
|
| Rate for Payer: EmblemHealth Medicaid |
$19.37
|
| Rate for Payer: EmblemHealth Medicare |
$8.23
|
| Rate for Payer: EmblemHealth Select Care |
$17.43
|
| Rate for Payer: Fidelis Medicare |
$9.23
|
| Rate for Payer: Galaxy Health Commercial |
$15.74
|
| Rate for Payer: Hamaspik Choice Medicare |
$8.96
|
| Rate for Payer: Humana Medicare |
$8.96
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$16.95
|
| Rate for Payer: Local 1199SEIU Medicare |
$11.14
|
| Rate for Payer: MVP Health Care of NY Commercial |
$18.16
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$13.63
|
| Rate for Payer: MVP Health Care of NY Medicare |
$9.41
|
| Rate for Payer: United Healthcare Medicare |
$8.96
|
| Rate for Payer: WellCare Medicare |
$13.32
|
|
|
SULFACETAMIDE SODIUM 0.1 DROP 15 ML
|
Facility
OP
|
$188.49
|
|
| Hospital Charge Code |
4400727
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$64.09 |
| Max. Negotiated Rate |
$151.73 |
| Rate for Payer: Aetna of NY Commercial |
$131.94
|
| Rate for Payer: Aetna of NY Medicare |
$86.71
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$141.37
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$141.37
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$69.74
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$94.24
|
| Rate for Payer: Cash Price |
$141.37
|
| Rate for Payer: CDPHP Commercial |
$151.73
|
| Rate for Payer: CDPHP Medicare |
$69.74
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$150.79
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$150.79
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$150.79
|
| Rate for Payer: EmblemHealth Medicaid |
$150.79
|
| Rate for Payer: EmblemHealth Medicare |
$64.09
|
| Rate for Payer: EmblemHealth Select Care |
$135.71
|
| Rate for Payer: Fidelis Medicare |
$71.83
|
| Rate for Payer: Galaxy Health Commercial |
$122.52
|
| Rate for Payer: Hamaspik Choice Medicare |
$69.74
|
| Rate for Payer: Humana Medicare |
$69.74
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$131.94
|
| Rate for Payer: Local 1199SEIU Medicare |
$86.71
|
| Rate for Payer: MVP Health Care of NY Commercial |
$141.37
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$106.12
|
| Rate for Payer: MVP Health Care of NY Medicare |
$73.23
|
| Rate for Payer: United Healthcare Medicare |
$69.74
|
| Rate for Payer: WellCare Medicare |
$103.67
|
|
|
SULFAMETHOXAZOLE AND TRIMETHOPRIM
|
Facility
OP
|
$6.00
|
|
| Hospital Charge Code |
4408938
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.04 |
| Max. Negotiated Rate |
$4.83 |
| Rate for Payer: Aetna of NY Commercial |
$4.20
|
| Rate for Payer: Aetna of NY Medicare |
$2.76
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$4.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$4.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$2.22
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$3.00
|
| Rate for Payer: Cash Price |
$4.50
|
| Rate for Payer: CDPHP Commercial |
$4.83
|
| Rate for Payer: CDPHP Medicare |
$2.22
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$4.80
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$4.80
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$4.80
|
| Rate for Payer: EmblemHealth Medicaid |
$4.80
|
| Rate for Payer: EmblemHealth Medicare |
$2.04
|
| Rate for Payer: EmblemHealth Select Care |
$4.32
|
| Rate for Payer: Fidelis Medicare |
$2.29
|
| Rate for Payer: Galaxy Health Commercial |
$3.90
|
| Rate for Payer: Hamaspik Choice Medicare |
$2.22
|
| Rate for Payer: Humana Medicare |
$2.22
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$4.20
|
| Rate for Payer: Local 1199SEIU Medicare |
$2.76
|
| Rate for Payer: MVP Health Care of NY Commercial |
$4.50
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$3.38
|
| Rate for Payer: MVP Health Care of NY Medicare |
$2.33
|
| Rate for Payer: United Healthcare Medicare |
$2.22
|
| Rate for Payer: WellCare Medicare |
$3.30
|
|
|
SULFAMETHOXAZOLE/TMP 800-160MG TABS 10X1
|
Facility
OP
|
$6.18
|
|
| Hospital Charge Code |
4400728
|
|
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
|
|
|
SULFAMETHOXAZOLE-TMP SUSP 200 mL, 20 mL
|
Facility
OP
|
$30.00
|
|
| Hospital Charge Code |
4401487
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.20 |
| Max. Negotiated Rate |
$24.15 |
| Rate for Payer: Aetna of NY Commercial |
$21.00
|
| Rate for Payer: Aetna of NY Medicare |
$13.80
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$22.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$22.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$11.10
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$15.00
|
| Rate for Payer: Cash Price |
$22.50
|
| Rate for Payer: CDPHP Commercial |
$24.15
|
| Rate for Payer: CDPHP Medicare |
$11.10
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$24.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$24.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$24.00
|
| Rate for Payer: EmblemHealth Medicaid |
$24.00
|
| Rate for Payer: EmblemHealth Medicare |
$10.20
|
| Rate for Payer: EmblemHealth Select Care |
$21.60
|
| Rate for Payer: Fidelis Medicare |
$11.43
|
| Rate for Payer: Galaxy Health Commercial |
$19.50
|
| Rate for Payer: Hamaspik Choice Medicare |
$11.10
|
| Rate for Payer: Humana Medicare |
$11.10
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$21.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$13.80
|
| Rate for Payer: MVP Health Care of NY Commercial |
$22.50
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$16.89
|
| Rate for Payer: MVP Health Care of NY Medicare |
$11.66
|
| Rate for Payer: United Healthcare Medicare |
$11.10
|
| Rate for Payer: WellCare Medicare |
$16.50
|
|
|
SULFAMETHOXAZOLE/TRIMETHOPRIM INJECTION 400/80, 5 ML INJECTION
|
Facility
OP
|
$20.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
4401293
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.80 |
| Max. Negotiated Rate |
$16.10 |
| Rate for Payer: Aetna of NY Commercial |
$11.00
|
| Rate for Payer: Aetna of NY Medicare |
$9.20
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$9.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$9.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$7.40
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$10.00
|
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: CDPHP Commercial |
$16.10
|
| Rate for Payer: CDPHP Medicare |
$7.40
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$16.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$16.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$16.00
|
| Rate for Payer: EmblemHealth Medicaid |
$16.00
|
| Rate for Payer: EmblemHealth Medicare |
$6.80
|
| Rate for Payer: EmblemHealth Select Care |
$14.40
|
| Rate for Payer: Fidelis Medicare |
$7.62
|
| Rate for Payer: Galaxy Health Commercial |
$13.00
|
| Rate for Payer: Hamaspik Choice Medicare |
$7.40
|
| Rate for Payer: Humana Medicare |
$7.40
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$11.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$9.20
|
| Rate for Payer: MVP Health Care of NY Commercial |
$15.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$11.26
|
| Rate for Payer: MVP Health Care of NY Medicare |
$7.77
|
| Rate for Payer: United Healthcare Medicare |
$7.40
|
| Rate for Payer: WellCare Medicare |
$11.00
|
|
|
SULFASALAZINE 500 MG TABLET
|
Facility
OP
|
$6.18
|
|
| Hospital Charge Code |
4409215
|
|
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
|
|
|
SUMATRIPTAN SUCCINATE INJ, 6 MG
|
Facility
OP
|
$96.31
|
|
|
Service Code
|
HCPCS J3030
|
| Hospital Charge Code |
4400729
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$32.75 |
| Max. Negotiated Rate |
$267.37 |
| Rate for Payer: Aetna of NY Commercial |
$52.97
|
| Rate for Payer: Aetna of NY Medicare |
$44.30
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$43.34
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$43.34
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$35.63
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$48.16
|
| Rate for Payer: Cash Price |
$72.23
|
| Rate for Payer: Cash Price |
$72.23
|
| Rate for Payer: CDPHP Commercial |
$77.53
|
| Rate for Payer: CDPHP Medicare |
$35.63
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$77.05
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$77.05
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$77.05
|
| Rate for Payer: EmblemHealth Medicaid |
$77.05
|
| Rate for Payer: EmblemHealth Medicare |
$32.75
|
| Rate for Payer: EmblemHealth Select Care |
$69.34
|
| Rate for Payer: Fidelis Medicare |
$36.70
|
| Rate for Payer: Galaxy Health Commercial |
$62.60
|
| Rate for Payer: Hamaspik Choice Medicare |
$35.63
|
| Rate for Payer: Humana Medicare |
$35.63
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$52.97
|
| Rate for Payer: Local 1199SEIU Medicare |
$44.30
|
| Rate for Payer: MVP Health Care of NY Commercial |
$72.23
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$54.22
|
| Rate for Payer: MVP Health Care of NY Medicare |
$37.42
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$267.37
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$164.79
|
| Rate for Payer: United Healthcare Commercial |
$267.37
|
| Rate for Payer: United Healthcare Medicare |
$35.63
|
| Rate for Payer: WellCare Medicare |
$52.97
|
|
|
SUPER QUICK ANCHOR PLUS #212032
|
Facility
OP
|
$1,713.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4479268
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$582.42 |
| Max. Negotiated Rate |
$1,378.96 |
| Rate for Payer: Aetna of NY Commercial |
$1,199.10
|
| Rate for Payer: Aetna of NY Medicare |
$787.98
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$770.85
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$770.85
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$633.81
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$856.50
|
| Rate for Payer: Cash Price |
$1,284.75
|
| Rate for Payer: CDPHP Commercial |
$1,378.96
|
| Rate for Payer: CDPHP Medicare |
$633.81
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$856.50
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$1,370.40
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$1,370.40
|
| Rate for Payer: EmblemHealth Medicaid |
$1,370.40
|
| Rate for Payer: EmblemHealth Medicare |
$582.42
|
| Rate for Payer: EmblemHealth Select Care |
$856.50
|
| Rate for Payer: Fidelis Medicare |
$652.82
|
| Rate for Payer: Galaxy Health Commercial |
$1,113.45
|
| Rate for Payer: Hamaspik Choice Medicare |
$633.81
|
| Rate for Payer: Humana Medicare |
$633.81
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,199.10
|
| Rate for Payer: Local 1199SEIU Medicare |
$787.98
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,113.45
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$1,113.45
|
| Rate for Payer: MVP Health Care of NY Medicare |
$665.50
|
| Rate for Payer: United Healthcare Medicare |
$633.81
|
| Rate for Payer: WellCare Medicare |
$942.15
|
|
|
SUPRANE
|
Facility
OP
|
$6.18
|
|
| Hospital Charge Code |
4409116
|
|
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
|
|
|
SUPRAPUBIC CATH SET 14 FR
|
Facility
OP
|
$363.00
|
|
|
Service Code
|
HCPCS C2627
|
| Hospital Charge Code |
4471056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$123.42 |
| Max. Negotiated Rate |
$292.22 |
| Rate for Payer: Aetna of NY Commercial |
$254.10
|
| Rate for Payer: Aetna of NY Medicare |
$166.98
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$272.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$272.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$134.31
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$181.50
|
| Rate for Payer: Cash Price |
$272.25
|
| Rate for Payer: CDPHP Commercial |
$292.22
|
| Rate for Payer: CDPHP Medicare |
$134.31
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$290.40
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$290.40
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$290.40
|
| Rate for Payer: EmblemHealth Medicaid |
$290.40
|
| Rate for Payer: EmblemHealth Medicare |
$123.42
|
| Rate for Payer: EmblemHealth Select Care |
$261.36
|
| Rate for Payer: Fidelis Medicare |
$138.34
|
| Rate for Payer: Galaxy Health Commercial |
$235.95
|
| Rate for Payer: Hamaspik Choice Medicare |
$134.31
|
| Rate for Payer: Humana Medicare |
$134.31
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$254.10
|
| Rate for Payer: Local 1199SEIU Medicare |
$166.98
|
| Rate for Payer: MVP Health Care of NY Commercial |
$272.25
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$204.37
|
| Rate for Payer: MVP Health Care of NY Medicare |
$141.03
|
| Rate for Payer: United Healthcare Medicare |
$134.31
|
| Rate for Payer: WellCare Medicare |
$199.65
|
|
