|
GASTRIC EMPTYING STUDY
|
Facility
|
IP
|
$115.00
|
|
|
Service Code
|
HCPCS 78264 26
|
| Hospital Charge Code |
5210013
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$74.75 |
| Max. Negotiated Rate |
$74.75 |
| Rate for Payer: Cash Price |
$86.25
|
| Rate for Payer: Galaxy Health Commercial |
$74.75
|
|
|
GASTRIC EMPTYING STUDY
|
Facility
|
OP
|
$1,225.00
|
|
|
Service Code
|
HCPCS 78264
|
| Hospital Charge Code |
4210013
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$183.75 |
| Max. Negotiated Rate |
$1,545.00 |
| Rate for Payer: Aetna of NY Commercial |
$857.50
|
| Rate for Payer: Aetna of NY Medicare |
$563.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$490.00
|
| Rate for Payer: Cash Price |
$918.75
|
| Rate for Payer: Cash Price |
$918.75
|
| Rate for Payer: CDPHP Medicare |
$453.25
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$857.50
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$980.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$980.00
|
| Rate for Payer: EmblemHealth Medicaid |
$980.00
|
| Rate for Payer: EmblemHealth Medicare |
$416.50
|
| Rate for Payer: EmblemHealth Select Care |
$796.25
|
| Rate for Payer: Fidelis Medicare |
$490.00
|
| Rate for Payer: Galaxy Health Commercial |
$796.25
|
| Rate for Payer: Hamaspik Choice Medicare |
$490.00
|
| Rate for Payer: Humana Medicare |
$490.00
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$857.50
|
| Rate for Payer: Local 1199SEIU Medicare |
$563.50
|
| Rate for Payer: MVP Health Care of NY Commercial |
$918.75
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$689.67
|
| Rate for Payer: MVP Health Care of NY Medicare |
$514.50
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$1,545.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$183.75
|
| Rate for Payer: United Healthcare Commercial |
$1,545.00
|
| Rate for Payer: United Healthcare Medicare |
$490.00
|
| Rate for Payer: WellCare Medicare |
$673.75
|
|
|
GASTRIC EMPTYING STUDY
|
Facility
|
OP
|
$115.00
|
|
|
Service Code
|
HCPCS 78264 26
|
| Hospital Charge Code |
5210013
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$17.25 |
| Max. Negotiated Rate |
$92.00 |
| Rate for Payer: Aetna of NY Commercial |
$80.50
|
| Rate for Payer: Aetna of NY Medicare |
$52.90
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$46.00
|
| Rate for Payer: Cash Price |
$86.25
|
| Rate for Payer: CDPHP Medicare |
$42.55
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$92.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$92.00
|
| Rate for Payer: EmblemHealth Medicaid |
$92.00
|
| Rate for Payer: EmblemHealth Medicare |
$39.10
|
| Rate for Payer: Fidelis Medicare |
$46.00
|
| Rate for Payer: Galaxy Health Commercial |
$74.75
|
| Rate for Payer: Hamaspik Choice Medicare |
$46.00
|
| Rate for Payer: Humana Medicare |
$46.00
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$80.50
|
| Rate for Payer: Local 1199SEIU Medicare |
$52.90
|
| Rate for Payer: MVP Health Care of NY Commercial |
$86.25
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$64.75
|
| Rate for Payer: MVP Health Care of NY Medicare |
$48.30
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$17.25
|
| Rate for Payer: United Healthcare Medicare |
$46.00
|
| Rate for Payer: WellCare Medicare |
$63.25
|
|
|
GASTRIC EMPTYING STUDY
|
Facility
|
IP
|
$1,225.00
|
|
|
Service Code
|
HCPCS 78264
|
| Hospital Charge Code |
4210013
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$796.25 |
| Max. Negotiated Rate |
$796.25 |
| Rate for Payer: Cash Price |
$918.75
|
| Rate for Payer: Galaxy Health Commercial |
$796.25
|
|
|
GASTROESOPHAGEAL REFLUX STUDY
|
Facility
|
IP
|
$1,225.00
|
|
|
Service Code
|
HCPCS 78262
|
| Hospital Charge Code |
4210014
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$796.25 |
| Max. Negotiated Rate |
$796.25 |
| Rate for Payer: Cash Price |
$918.75
|
| Rate for Payer: Galaxy Health Commercial |
$796.25
|
|
|
GASTROESOPHAGEAL REFLUX STUDY
|
Facility
|
IP
|
$100.00
|
|
|
Service Code
|
HCPCS 78262 26
|
| Hospital Charge Code |
5210014
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$65.00 |
| Max. Negotiated Rate |
$65.00 |
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Galaxy Health Commercial |
$65.00
|
|
|
GASTROESOPHAGEAL REFLUX STUDY
|
Facility
|
OP
|
$100.00
|
|
|
Service Code
|
HCPCS 78262 26
|
| Hospital Charge Code |
5210014
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$15.00 |
| Max. Negotiated Rate |
$80.00 |
| Rate for Payer: Aetna of NY Commercial |
$70.00
|
| Rate for Payer: Aetna of NY Medicare |
$46.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$40.00
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: CDPHP Medicare |
$37.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$80.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$80.00
|
| Rate for Payer: EmblemHealth Medicaid |
$80.00
|
| Rate for Payer: EmblemHealth Medicare |
$34.00
|
| Rate for Payer: Fidelis Medicare |
$40.00
|
| Rate for Payer: Galaxy Health Commercial |
$65.00
|
| Rate for Payer: Hamaspik Choice Medicare |
$40.00
|
| Rate for Payer: Humana Medicare |
$40.00
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$70.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$46.00
|
| Rate for Payer: MVP Health Care of NY Commercial |
$75.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$56.30
|
| Rate for Payer: MVP Health Care of NY Medicare |
$42.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$15.00
|
| Rate for Payer: United Healthcare Medicare |
$40.00
|
| Rate for Payer: WellCare Medicare |
$55.00
|
|
|
GASTROESOPHAGEAL REFLUX STUDY
|
Facility
|
OP
|
$1,225.00
|
|
|
Service Code
|
HCPCS 78262
|
| Hospital Charge Code |
4210014
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$183.75 |
| Max. Negotiated Rate |
$1,545.00 |
| Rate for Payer: Aetna of NY Commercial |
$857.50
|
| Rate for Payer: Aetna of NY Medicare |
$563.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$490.00
|
| Rate for Payer: Cash Price |
$918.75
|
| Rate for Payer: Cash Price |
$918.75
|
| Rate for Payer: CDPHP Medicare |
$453.25
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$857.50
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$980.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$980.00
|
| Rate for Payer: EmblemHealth Medicaid |
$980.00
|
| Rate for Payer: EmblemHealth Medicare |
$416.50
|
| Rate for Payer: EmblemHealth Select Care |
$796.25
|
| Rate for Payer: Fidelis Medicare |
$490.00
|
| Rate for Payer: Galaxy Health Commercial |
$796.25
|
| Rate for Payer: Hamaspik Choice Medicare |
$490.00
|
| Rate for Payer: Humana Medicare |
$490.00
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$857.50
|
| Rate for Payer: Local 1199SEIU Medicare |
$563.50
|
| Rate for Payer: MVP Health Care of NY Commercial |
$918.75
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$689.67
|
| Rate for Payer: MVP Health Care of NY Medicare |
$514.50
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$1,545.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$183.75
|
| Rate for Payer: United Healthcare Commercial |
$1,545.00
|
| Rate for Payer: United Healthcare Medicare |
$490.00
|
| Rate for Payer: WellCare Medicare |
$673.75
|
|
|
GASTROGRAFFIN 120ML
|
Facility
|
OP
|
$75.19
|
|
|
Service Code
|
HCPCS C1763
|
| Hospital Charge Code |
4471048
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$11.28 |
| Max. Negotiated Rate |
$60.15 |
| Rate for Payer: Aetna of NY Commercial |
$52.63
|
| Rate for Payer: Aetna of NY Medicare |
$34.59
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$30.08
|
| Rate for Payer: Cash Price |
$56.39
|
| Rate for Payer: CDPHP Medicare |
$27.82
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$37.59
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$60.15
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$60.15
|
| Rate for Payer: EmblemHealth Medicaid |
$60.15
|
| Rate for Payer: EmblemHealth Medicare |
$25.56
|
| Rate for Payer: EmblemHealth Select Care |
$37.59
|
| Rate for Payer: Fidelis Medicare |
$30.08
|
| Rate for Payer: Galaxy Health Commercial |
$48.87
|
| Rate for Payer: Hamaspik Choice Medicare |
$30.08
|
| Rate for Payer: Humana Medicare |
$30.08
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$52.63
|
| Rate for Payer: Local 1199SEIU Medicare |
$34.59
|
| Rate for Payer: MVP Health Care of NY Commercial |
$48.87
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$48.87
|
| Rate for Payer: MVP Health Care of NY Medicare |
$31.58
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$11.28
|
| Rate for Payer: United Healthcare Medicare |
$30.08
|
| Rate for Payer: WellCare Medicare |
$41.35
|
|
|
GASTROGRAFFIN 120ML
|
Facility
|
IP
|
$75.19
|
|
|
Service Code
|
HCPCS C1763
|
| Hospital Charge Code |
4471048
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$33.84 |
| Max. Negotiated Rate |
$52.63 |
| Rate for Payer: Aetna of NY Commercial |
$52.63
|
| Rate for Payer: Cash Price |
$56.39
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$37.59
|
| Rate for Payer: EmblemHealth Select Care |
$37.59
|
| Rate for Payer: Galaxy Health Commercial |
$48.87
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$52.63
|
| Rate for Payer: Multiplan Commercial |
$33.84
|
| Rate for Payer: MVP Health Care of NY Commercial |
$48.87
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$48.87
|
| Rate for Payer: WellCare Medicare |
$41.35
|
|
|
GB SCAN W DRUG
|
Facility
|
IP
|
$130.00
|
|
|
Service Code
|
HCPCS 78227 26
|
| Hospital Charge Code |
5211247
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$84.50 |
| Max. Negotiated Rate |
$84.50 |
| Rate for Payer: Cash Price |
$97.50
|
| Rate for Payer: Galaxy Health Commercial |
$84.50
|
|
|
GB SCAN W DRUG
|
Facility
|
OP
|
$1,664.00
|
|
|
Service Code
|
HCPCS 78227
|
| Hospital Charge Code |
4211247
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$249.60 |
| Max. Negotiated Rate |
$1,545.00 |
| Rate for Payer: Aetna of NY Commercial |
$1,164.80
|
| Rate for Payer: Aetna of NY Medicare |
$765.44
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$665.60
|
| Rate for Payer: Cash Price |
$1,248.00
|
| Rate for Payer: Cash Price |
$1,248.00
|
| Rate for Payer: CDPHP Medicare |
$615.68
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$1,164.80
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$1,331.20
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$1,331.20
|
| Rate for Payer: EmblemHealth Medicaid |
$1,331.20
|
| Rate for Payer: EmblemHealth Medicare |
$565.76
|
| Rate for Payer: EmblemHealth Select Care |
$1,081.60
|
| Rate for Payer: Fidelis Medicare |
$665.60
|
| Rate for Payer: Galaxy Health Commercial |
$1,081.60
|
| Rate for Payer: Hamaspik Choice Medicare |
$665.60
|
| Rate for Payer: Humana Medicare |
$665.60
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,164.80
|
| Rate for Payer: Local 1199SEIU Medicare |
$765.44
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,248.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$936.83
|
| Rate for Payer: MVP Health Care of NY Medicare |
$698.88
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$1,545.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$249.60
|
| Rate for Payer: United Healthcare Commercial |
$1,545.00
|
| Rate for Payer: United Healthcare Medicare |
$665.60
|
| Rate for Payer: WellCare Medicare |
$915.20
|
|
|
GB SCAN W DRUG
|
Facility
|
OP
|
$130.00
|
|
|
Service Code
|
HCPCS 78227 26
|
| Hospital Charge Code |
5211247
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$19.50 |
| Max. Negotiated Rate |
$104.00 |
| Rate for Payer: Aetna of NY Commercial |
$91.00
|
| Rate for Payer: Aetna of NY Medicare |
$59.80
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$52.00
|
| Rate for Payer: Cash Price |
$97.50
|
| Rate for Payer: CDPHP Medicare |
$48.10
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$104.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$104.00
|
| Rate for Payer: EmblemHealth Medicaid |
$104.00
|
| Rate for Payer: EmblemHealth Medicare |
$44.20
|
| Rate for Payer: Fidelis Medicare |
$52.00
|
| Rate for Payer: Galaxy Health Commercial |
$84.50
|
| Rate for Payer: Hamaspik Choice Medicare |
$52.00
|
| Rate for Payer: Humana Medicare |
$52.00
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$91.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$59.80
|
| Rate for Payer: MVP Health Care of NY Commercial |
$97.50
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$73.19
|
| Rate for Payer: MVP Health Care of NY Medicare |
$54.60
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$19.50
|
| Rate for Payer: United Healthcare Medicare |
$52.00
|
| Rate for Payer: WellCare Medicare |
$71.50
|
|
|
GB SCAN W DRUG
|
Facility
|
IP
|
$1,664.00
|
|
|
Service Code
|
HCPCS 78227
|
| Hospital Charge Code |
4211247
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$1,081.60 |
| Max. Negotiated Rate |
$1,081.60 |
| Rate for Payer: Cash Price |
$1,248.00
|
| Rate for Payer: Galaxy Health Commercial |
$1,081.60
|
|
|
GB SCAN W/O DRUG
|
Facility
|
OP
|
$1,225.00
|
|
|
Service Code
|
HCPCS 78226
|
| Hospital Charge Code |
4210016
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$183.75 |
| Max. Negotiated Rate |
$1,545.00 |
| Rate for Payer: Aetna of NY Commercial |
$857.50
|
| Rate for Payer: Aetna of NY Medicare |
$563.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$490.00
|
| Rate for Payer: Cash Price |
$918.75
|
| Rate for Payer: Cash Price |
$918.75
|
| Rate for Payer: CDPHP Medicare |
$453.25
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$857.50
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$980.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$980.00
|
| Rate for Payer: EmblemHealth Medicaid |
$980.00
|
| Rate for Payer: EmblemHealth Medicare |
$416.50
|
| Rate for Payer: EmblemHealth Select Care |
$796.25
|
| Rate for Payer: Fidelis Medicare |
$490.00
|
| Rate for Payer: Galaxy Health Commercial |
$796.25
|
| Rate for Payer: Hamaspik Choice Medicare |
$490.00
|
| Rate for Payer: Humana Medicare |
$490.00
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$857.50
|
| Rate for Payer: Local 1199SEIU Medicare |
$563.50
|
| Rate for Payer: MVP Health Care of NY Commercial |
$918.75
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$689.67
|
| Rate for Payer: MVP Health Care of NY Medicare |
$514.50
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$1,545.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$183.75
|
| Rate for Payer: United Healthcare Commercial |
$1,545.00
|
| Rate for Payer: United Healthcare Medicare |
$490.00
|
| Rate for Payer: WellCare Medicare |
$673.75
|
|
|
GB SCAN W/O DRUG
|
Facility
|
IP
|
$1,225.00
|
|
|
Service Code
|
HCPCS 78226
|
| Hospital Charge Code |
4210016
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$796.25 |
| Max. Negotiated Rate |
$796.25 |
| Rate for Payer: Cash Price |
$918.75
|
| Rate for Payer: Galaxy Health Commercial |
$796.25
|
|
|
GB SCAN W/O DRUG
|
Facility
|
OP
|
$107.00
|
|
|
Service Code
|
HCPCS 78226 26
|
| Hospital Charge Code |
5210016
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$16.05 |
| Max. Negotiated Rate |
$85.60 |
| Rate for Payer: Aetna of NY Commercial |
$74.90
|
| Rate for Payer: Aetna of NY Medicare |
$49.22
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$42.80
|
| Rate for Payer: Cash Price |
$80.25
|
| Rate for Payer: CDPHP Medicare |
$39.59
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$85.60
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$85.60
|
| Rate for Payer: EmblemHealth Medicaid |
$85.60
|
| Rate for Payer: EmblemHealth Medicare |
$36.38
|
| Rate for Payer: Fidelis Medicare |
$42.80
|
| Rate for Payer: Galaxy Health Commercial |
$69.55
|
| Rate for Payer: Hamaspik Choice Medicare |
$42.80
|
| Rate for Payer: Humana Medicare |
$42.80
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$74.90
|
| Rate for Payer: Local 1199SEIU Medicare |
$49.22
|
| Rate for Payer: MVP Health Care of NY Commercial |
$80.25
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$60.24
|
| Rate for Payer: MVP Health Care of NY Medicare |
$44.94
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$16.05
|
| Rate for Payer: United Healthcare Medicare |
$42.80
|
| Rate for Payer: WellCare Medicare |
$58.85
|
|
|
GB SCAN W/O DRUG
|
Facility
|
IP
|
$107.00
|
|
|
Service Code
|
HCPCS 78226 26
|
| Hospital Charge Code |
5210016
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$69.55 |
| Max. Negotiated Rate |
$69.55 |
| Rate for Payer: Cash Price |
$80.25
|
| Rate for Payer: Galaxy Health Commercial |
$69.55
|
|
|
GELSYN-3 16.8 MG/2 ML SYRINGE 16.8 mg, 2 mL
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J7328
|
| Hospital Charge Code |
4401552
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.68 |
| Max. Negotiated Rate |
$6.40 |
| Rate for Payer: Aetna of NY Medicare |
$3.68
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$3.20
|
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: CDPHP Medicare |
$2.96
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$0.68
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$6.40
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$6.40
|
| Rate for Payer: EmblemHealth Medicaid |
$6.40
|
| Rate for Payer: EmblemHealth Medicare |
$2.72
|
| Rate for Payer: EmblemHealth Select Care |
$0.68
|
| Rate for Payer: Fidelis Medicare |
$3.20
|
| Rate for Payer: Galaxy Health Commercial |
$5.20
|
| Rate for Payer: Hamaspik Choice Medicare |
$3.20
|
| Rate for Payer: Humana Medicare |
$3.20
|
| Rate for Payer: Local 1199SEIU Medicare |
$3.68
|
| Rate for Payer: MVP Health Care of NY Commercial |
$6.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$4.50
|
| Rate for Payer: MVP Health Care of NY Medicare |
$3.36
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$1.02
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$1.20
|
| Rate for Payer: United Healthcare Commercial |
$1.02
|
| Rate for Payer: United Healthcare Medicare |
$3.20
|
| Rate for Payer: WellCare Medicare |
$4.40
|
|
|
GELSYN-3 16.8 MG/2 ML SYRINGE 16.8 mg, 2 mL
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J7328
|
| Hospital Charge Code |
4401552
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.68 |
| Max. Negotiated Rate |
$5.20 |
| Rate for Payer: Aetna of NY Commercial |
$4.40
|
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$0.68
|
| Rate for Payer: EmblemHealth Select Care |
$0.68
|
| Rate for Payer: Galaxy Health Commercial |
$5.20
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$4.40
|
| Rate for Payer: WellCare Medicare |
$4.40
|
|
|
GEMFIBROZIL 600MG TABS 25 EA
|
Facility
|
IP
|
$13.65
|
|
|
Service Code
|
NDC 50268035015
|
| Hospital Charge Code |
4400318
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.51 |
| Max. Negotiated Rate |
$8.87 |
| Rate for Payer: Cash Price |
$10.24
|
| Rate for Payer: Galaxy Health Commercial |
$8.87
|
| Rate for Payer: WellCare Medicare |
$7.51
|
|
|
GEMFIBROZIL 600MG TABS 25 EA
|
Facility
|
OP
|
$13.65
|
|
|
Service Code
|
NDC 50268035015
|
| Hospital Charge Code |
4400318
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.05 |
| Max. Negotiated Rate |
$10.92 |
| Rate for Payer: Aetna of NY Commercial |
$9.55
|
| Rate for Payer: Aetna of NY Medicare |
$6.28
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$5.46
|
| Rate for Payer: Cash Price |
$10.24
|
| Rate for Payer: CDPHP Medicare |
$5.05
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$10.92
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$10.92
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$10.92
|
| Rate for Payer: EmblemHealth Medicaid |
$10.92
|
| Rate for Payer: EmblemHealth Medicare |
$4.64
|
| Rate for Payer: EmblemHealth Select Care |
$9.83
|
| Rate for Payer: Fidelis Medicare |
$5.46
|
| Rate for Payer: Galaxy Health Commercial |
$8.87
|
| Rate for Payer: Hamaspik Choice Medicare |
$5.46
|
| Rate for Payer: Humana Medicare |
$5.46
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$9.55
|
| Rate for Payer: Local 1199SEIU Medicare |
$6.28
|
| Rate for Payer: MVP Health Care of NY Commercial |
$10.24
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$7.68
|
| Rate for Payer: MVP Health Care of NY Medicare |
$5.73
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$2.05
|
| Rate for Payer: United Healthcare Medicare |
$5.46
|
| Rate for Payer: WellCare Medicare |
$7.51
|
|
|
GEN COOLED PROBE NO TIP CRI-17-100
|
Facility
|
OP
|
$419.21
|
|
| Hospital Charge Code |
4479259
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$62.88 |
| Max. Negotiated Rate |
$335.37 |
| Rate for Payer: Aetna of NY Commercial |
$293.45
|
| Rate for Payer: Aetna of NY Medicare |
$192.84
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$167.68
|
| Rate for Payer: Cash Price |
$314.41
|
| Rate for Payer: CDPHP Medicare |
$155.11
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$335.37
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$335.37
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$335.37
|
| Rate for Payer: EmblemHealth Medicaid |
$335.37
|
| Rate for Payer: EmblemHealth Medicare |
$142.53
|
| Rate for Payer: EmblemHealth Select Care |
$301.83
|
| Rate for Payer: Fidelis Medicare |
$167.68
|
| Rate for Payer: Galaxy Health Commercial |
$272.49
|
| Rate for Payer: Hamaspik Choice Medicare |
$167.68
|
| Rate for Payer: Humana Medicare |
$167.68
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$293.45
|
| Rate for Payer: Local 1199SEIU Medicare |
$192.84
|
| Rate for Payer: MVP Health Care of NY Commercial |
$314.41
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$236.02
|
| Rate for Payer: MVP Health Care of NY Medicare |
$176.07
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$62.88
|
| Rate for Payer: United Healthcare Medicare |
$167.68
|
| Rate for Payer: WellCare Medicare |
$230.57
|
|
|
GEN COOLED PROBE NO TIP CRI-17-100
|
Facility
|
IP
|
$419.21
|
|
| Hospital Charge Code |
4479259
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$272.49 |
| Max. Negotiated Rate |
$272.49 |
| Rate for Payer: Cash Price |
$314.41
|
| Rate for Payer: Galaxy Health Commercial |
$272.49
|
|
|
GEN COOLED RF GUAGE CRP-17-75-4
|
Facility
|
OP
|
$2,190.81
|
|
| Hospital Charge Code |
4479261
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$328.62 |
| Max. Negotiated Rate |
$1,752.65 |
| Rate for Payer: Aetna of NY Commercial |
$1,533.57
|
| Rate for Payer: Aetna of NY Medicare |
$1,007.77
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$876.32
|
| Rate for Payer: Cash Price |
$1,643.11
|
| Rate for Payer: CDPHP Medicare |
$810.60
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$1,752.65
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$1,752.65
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$1,752.65
|
| Rate for Payer: EmblemHealth Medicaid |
$1,752.65
|
| Rate for Payer: EmblemHealth Medicare |
$744.88
|
| Rate for Payer: EmblemHealth Select Care |
$1,577.38
|
| Rate for Payer: Fidelis Medicare |
$876.32
|
| Rate for Payer: Galaxy Health Commercial |
$1,424.03
|
| Rate for Payer: Hamaspik Choice Medicare |
$876.32
|
| Rate for Payer: Humana Medicare |
$876.32
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,533.57
|
| Rate for Payer: Local 1199SEIU Medicare |
$1,007.77
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,643.11
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$1,233.43
|
| Rate for Payer: MVP Health Care of NY Medicare |
$920.14
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$328.62
|
| Rate for Payer: United Healthcare Medicare |
$876.32
|
| Rate for Payer: WellCare Medicare |
$1,204.95
|
|
