|
INS TEMP BLADDER CATH SIMPLE
|
Facility
|
OP
|
$366.00
|
|
|
Service Code
|
HCPCS 51702
|
| Hospital Charge Code |
4851253
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$121.71 |
| Max. Negotiated Rate |
$2,521.93 |
| Rate for Payer: Aetna of NY Commercial |
$256.20
|
| Rate for Payer: Aetna of NY Medicare |
$168.36
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$2,017.33
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$2,521.93
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$135.42
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$183.00
|
| Rate for Payer: Cash Price |
$274.50
|
| Rate for Payer: Cash Price |
$274.50
|
| Rate for Payer: Cash Price |
$274.50
|
| Rate for Payer: CDPHP Commercial |
$294.63
|
| Rate for Payer: CDPHP Medicare |
$135.42
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$292.80
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$292.80
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$292.80
|
| Rate for Payer: EmblemHealth Medicaid |
$292.80
|
| Rate for Payer: EmblemHealth Medicare |
$124.44
|
| Rate for Payer: EmblemHealth Select Care |
$263.52
|
| Rate for Payer: Fidelis Medicare |
$139.48
|
| Rate for Payer: Galaxy Health Commercial |
$237.90
|
| Rate for Payer: Hamaspik Choice Medicare |
$135.42
|
| Rate for Payer: Humana Medicare |
$135.42
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$256.20
|
| Rate for Payer: Local 1199SEIU Medicare |
$168.36
|
| Rate for Payer: MVP Health Care of NY Commercial |
$274.50
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$206.06
|
| Rate for Payer: MVP Health Care of NY Medicare |
$142.19
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$121.71
|
| Rate for Payer: United Healthcare Medicare |
$135.42
|
| Rate for Payer: WellCare Medicare |
$201.30
|
|
|
INS TEMP BLADDER CATH SIMPLE
|
Facility
|
IP
|
$366.00
|
|
|
Service Code
|
HCPCS 51702
|
| Hospital Charge Code |
4451253
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$237.90 |
| Max. Negotiated Rate |
$237.90 |
| Rate for Payer: Cash Price |
$274.50
|
| Rate for Payer: Galaxy Health Commercial |
$237.90
|
|
|
INS TEMP BLADDER CATH SIMPLE
|
Facility
|
IP
|
$366.00
|
|
|
Service Code
|
HCPCS 51702
|
| Hospital Charge Code |
4851253
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$237.90 |
| Max. Negotiated Rate |
$237.90 |
| Rate for Payer: Cash Price |
$274.50
|
| Rate for Payer: Galaxy Health Commercial |
$237.90
|
|
|
INS TEMP BLADDER CATH (STRAIGHT CATH)
|
Facility
|
OP
|
$366.00
|
|
|
Service Code
|
HCPCS 51701
|
| Hospital Charge Code |
4609611
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$121.71 |
| Max. Negotiated Rate |
$1,189.18 |
| Rate for Payer: Aetna of NY Commercial |
$955.00
|
| Rate for Payer: Aetna of NY Medicare |
$168.36
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$950.93
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$1,189.18
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$135.42
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$183.00
|
| Rate for Payer: Cash Price |
$274.50
|
| Rate for Payer: Cash Price |
$274.50
|
| Rate for Payer: Cash Price |
$274.50
|
| Rate for Payer: Cash Price |
$274.50
|
| Rate for Payer: CDPHP Commercial |
$294.63
|
| Rate for Payer: CDPHP Medicare |
$135.42
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$1,182.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$292.80
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$292.80
|
| Rate for Payer: EmblemHealth Medicaid |
$292.80
|
| Rate for Payer: EmblemHealth Medicare |
$124.44
|
| Rate for Payer: EmblemHealth Select Care |
$1,064.00
|
| Rate for Payer: Fidelis Child Health Plus/Essential Plan/HARP/Medicaid |
$250.00
|
| Rate for Payer: Fidelis Medicare |
$139.48
|
| Rate for Payer: Galaxy Health Commercial |
$237.90
|
| Rate for Payer: Hamaspik Choice Medicare |
$135.42
|
| Rate for Payer: Humana Medicare |
$135.42
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$955.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$168.36
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,174.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$881.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$142.19
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$980.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$121.71
|
| Rate for Payer: United Healthcare Commercial |
$980.00
|
| Rate for Payer: United Healthcare Medicare |
$135.42
|
| Rate for Payer: WellCare Medicare |
$201.30
|
|
|
INS TEMP BLADDER CATH (STRAIGHT CATH)
|
Facility
|
IP
|
$366.00
|
|
|
Service Code
|
HCPCS 51701
|
| Hospital Charge Code |
4609611
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$237.90 |
| Max. Negotiated Rate |
$237.90 |
| Rate for Payer: Cash Price |
$274.50
|
| Rate for Payer: Galaxy Health Commercial |
$237.90
|
|
|
INSULIN GLARGINE 100U/ML SYRN 5X3ML
|
Facility
|
OP
|
$276.56
|
|
|
Service Code
|
NDC 00088221905
|
| Hospital Charge Code |
4400415
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$94.03 |
| Max. Negotiated Rate |
$222.63 |
| Rate for Payer: Aetna of NY Commercial |
$193.59
|
| Rate for Payer: Aetna of NY Medicare |
$127.22
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$207.42
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$207.42
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$102.33
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$138.28
|
| Rate for Payer: Cash Price |
$207.42
|
| Rate for Payer: CDPHP Commercial |
$222.63
|
| Rate for Payer: CDPHP Medicare |
$102.33
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$221.25
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$221.25
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$221.25
|
| Rate for Payer: EmblemHealth Medicaid |
$221.25
|
| Rate for Payer: EmblemHealth Medicare |
$94.03
|
| Rate for Payer: EmblemHealth Select Care |
$199.12
|
| Rate for Payer: Fidelis Medicare |
$105.40
|
| Rate for Payer: Galaxy Health Commercial |
$179.76
|
| Rate for Payer: Hamaspik Choice Medicare |
$102.33
|
| Rate for Payer: Humana Medicare |
$102.33
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$193.59
|
| Rate for Payer: Local 1199SEIU Medicare |
$127.22
|
| Rate for Payer: MVP Health Care of NY Commercial |
$207.42
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$155.70
|
| Rate for Payer: MVP Health Care of NY Medicare |
$107.44
|
| Rate for Payer: United Healthcare Medicare |
$102.33
|
| Rate for Payer: WellCare Medicare |
$152.11
|
|
|
INSULIN GLARGINE 100U/ML SYRN 5X3ML
|
Facility
|
IP
|
$276.56
|
|
|
Service Code
|
NDC 00088221905
|
| Hospital Charge Code |
4400415
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$152.11 |
| Max. Negotiated Rate |
$179.76 |
| Rate for Payer: Cash Price |
$207.42
|
| Rate for Payer: Galaxy Health Commercial |
$179.76
|
| Rate for Payer: WellCare Medicare |
$152.11
|
|
|
INSULIN INJ PER 5 UNITS
|
Facility
|
IP
|
$299.22
|
|
|
Service Code
|
HCPCS J1815
|
| Hospital Charge Code |
4400427
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$134.65 |
| Max. Negotiated Rate |
$194.49 |
| Rate for Payer: Aetna of NY Commercial |
$164.57
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$134.65
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$134.65
|
| Rate for Payer: Cash Price |
$224.42
|
| Rate for Payer: Galaxy Health Commercial |
$194.49
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$164.57
|
| Rate for Payer: WellCare Medicare |
$164.57
|
|
|
INSULIN INJ PER 5 UNITS
|
Facility
|
OP
|
$6.18
|
|
|
Service Code
|
HCPCS J1815
|
| Hospital Charge Code |
4400353
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$4.97 |
| Rate for Payer: Aetna of NY Commercial |
$3.40
|
| Rate for Payer: Aetna of NY Medicare |
$2.84
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$2.78
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$2.78
|
| 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: 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 |
$3.40
|
| 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: Oxford Health Plans Freedom/Liberty/Metro |
$2.24
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$0.56
|
| Rate for Payer: United Healthcare Commercial |
$2.24
|
| Rate for Payer: United Healthcare Medicare |
$2.29
|
| Rate for Payer: WellCare Medicare |
$3.40
|
|
|
INSULIN INJ PER 5 UNITS
|
Facility
|
IP
|
$6.18
|
|
|
Service Code
|
HCPCS J1815
|
| Hospital Charge Code |
4400353
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.78 |
| Max. Negotiated Rate |
$4.02 |
| Rate for Payer: Aetna of NY Commercial |
$3.40
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$2.78
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$2.78
|
| Rate for Payer: Cash Price |
$4.64
|
| Rate for Payer: Galaxy Health Commercial |
$4.02
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$3.40
|
| Rate for Payer: WellCare Medicare |
$3.40
|
|
|
INSULIN INJ PER 5 UNITS
|
Facility
|
IP
|
$6.18
|
|
|
Service Code
|
HCPCS J1815
|
| Hospital Charge Code |
4400354
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.78 |
| Max. Negotiated Rate |
$4.02 |
| Rate for Payer: Aetna of NY Commercial |
$3.40
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$2.78
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$2.78
|
| Rate for Payer: Cash Price |
$4.64
|
| Rate for Payer: Galaxy Health Commercial |
$4.02
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$3.40
|
| Rate for Payer: WellCare Medicare |
$3.40
|
|
|
INSULIN INJ PER 5 UNITS
|
Facility
|
OP
|
$6.18
|
|
|
Service Code
|
HCPCS J1815
|
| Hospital Charge Code |
4400354
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$4.97 |
| Rate for Payer: Aetna of NY Commercial |
$3.40
|
| Rate for Payer: Aetna of NY Medicare |
$2.84
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$2.78
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$2.78
|
| 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: 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 |
$3.40
|
| 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: Oxford Health Plans Freedom/Liberty/Metro |
$2.24
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$0.56
|
| Rate for Payer: United Healthcare Commercial |
$2.24
|
| Rate for Payer: United Healthcare Medicare |
$2.29
|
| Rate for Payer: WellCare Medicare |
$3.40
|
|
|
INSULIN INJ PER 5 UNITS
|
Facility
|
OP
|
$299.22
|
|
|
Service Code
|
HCPCS J1815
|
| Hospital Charge Code |
4400427
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$240.87 |
| Rate for Payer: Aetna of NY Commercial |
$164.57
|
| Rate for Payer: Aetna of NY Medicare |
$137.64
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$134.65
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$134.65
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$110.71
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$149.61
|
| Rate for Payer: Cash Price |
$224.42
|
| Rate for Payer: Cash Price |
$224.42
|
| Rate for Payer: CDPHP Commercial |
$240.87
|
| Rate for Payer: CDPHP Medicare |
$110.71
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$239.38
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$239.38
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$239.38
|
| Rate for Payer: EmblemHealth Medicaid |
$239.38
|
| Rate for Payer: EmblemHealth Medicare |
$101.73
|
| Rate for Payer: EmblemHealth Select Care |
$215.44
|
| Rate for Payer: Fidelis Medicare |
$114.03
|
| Rate for Payer: Galaxy Health Commercial |
$194.49
|
| Rate for Payer: Hamaspik Choice Medicare |
$110.71
|
| Rate for Payer: Humana Medicare |
$110.71
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$164.57
|
| Rate for Payer: Local 1199SEIU Medicare |
$137.64
|
| Rate for Payer: MVP Health Care of NY Commercial |
$224.42
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$168.46
|
| Rate for Payer: MVP Health Care of NY Medicare |
$116.25
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$2.24
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$0.56
|
| Rate for Payer: United Healthcare Commercial |
$2.24
|
| Rate for Payer: United Healthcare Medicare |
$110.71
|
| Rate for Payer: WellCare Medicare |
$164.57
|
|
|
INSULIN SYRINGE LO-DOSE
|
Facility
|
OP
|
$22.00
|
|
| Hospital Charge Code |
4472015
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$7.48 |
| Max. Negotiated Rate |
$17.71 |
| Rate for Payer: Aetna of NY Commercial |
$15.40
|
| Rate for Payer: Aetna of NY Medicare |
$10.12
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$16.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$16.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$8.14
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$11.00
|
| Rate for Payer: Cash Price |
$16.50
|
| Rate for Payer: CDPHP Commercial |
$17.71
|
| Rate for Payer: CDPHP Medicare |
$8.14
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$17.60
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$17.60
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$17.60
|
| Rate for Payer: EmblemHealth Medicaid |
$17.60
|
| Rate for Payer: EmblemHealth Medicare |
$7.48
|
| Rate for Payer: EmblemHealth Select Care |
$15.84
|
| Rate for Payer: Fidelis Medicare |
$8.38
|
| Rate for Payer: Galaxy Health Commercial |
$14.30
|
| Rate for Payer: Hamaspik Choice Medicare |
$8.14
|
| Rate for Payer: Humana Medicare |
$8.14
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$15.40
|
| Rate for Payer: Local 1199SEIU Medicare |
$10.12
|
| Rate for Payer: MVP Health Care of NY Commercial |
$16.50
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$12.39
|
| Rate for Payer: MVP Health Care of NY Medicare |
$8.55
|
| Rate for Payer: United Healthcare Medicare |
$8.14
|
| Rate for Payer: WellCare Medicare |
$12.10
|
|
|
INSULIN SYRINGE LO-DOSE
|
Facility
|
IP
|
$22.00
|
|
| Hospital Charge Code |
4472015
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$14.30 |
| Max. Negotiated Rate |
$14.30 |
| Rate for Payer: Cash Price |
$16.50
|
| Rate for Payer: Galaxy Health Commercial |
$14.30
|
|
|
INTERMEDIATE 12.6 TO 20 CM
|
Facility
|
OP
|
$1,141.00
|
|
|
Service Code
|
HCPCS 12035
|
| Hospital Charge Code |
4609620
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$250.00 |
| Max. Negotiated Rate |
$1,189.18 |
| Rate for Payer: Aetna of NY Commercial |
$955.00
|
| Rate for Payer: Aetna of NY Medicare |
$524.86
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$950.93
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$1,189.18
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$422.17
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$570.50
|
| Rate for Payer: Cash Price |
$855.75
|
| Rate for Payer: Cash Price |
$855.75
|
| Rate for Payer: Cash Price |
$855.75
|
| Rate for Payer: Cash Price |
$855.75
|
| Rate for Payer: CDPHP Commercial |
$918.50
|
| Rate for Payer: CDPHP Medicare |
$422.17
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$1,182.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$912.80
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$912.80
|
| Rate for Payer: EmblemHealth Medicaid |
$912.80
|
| Rate for Payer: EmblemHealth Medicare |
$387.94
|
| Rate for Payer: EmblemHealth Select Care |
$1,064.00
|
| Rate for Payer: Fidelis Child Health Plus/Essential Plan/HARP/Medicaid |
$250.00
|
| Rate for Payer: Fidelis Medicare |
$434.84
|
| Rate for Payer: Galaxy Health Commercial |
$741.65
|
| Rate for Payer: Hamaspik Choice Medicare |
$422.17
|
| Rate for Payer: Humana Medicare |
$422.17
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$955.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$524.86
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,174.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$881.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$443.28
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$980.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$379.92
|
| Rate for Payer: United Healthcare Commercial |
$980.00
|
| Rate for Payer: United Healthcare Medicare |
$422.17
|
| Rate for Payer: WellCare Medicare |
$627.55
|
|
|
INTERMEDIATE 12.6 TO 20 CM
|
Facility
|
IP
|
$1,141.00
|
|
|
Service Code
|
HCPCS 12035
|
| Hospital Charge Code |
4609620
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$741.65 |
| Max. Negotiated Rate |
$741.65 |
| Rate for Payer: Cash Price |
$855.75
|
| Rate for Payer: Galaxy Health Commercial |
$741.65
|
|
|
INTERNAL NEUROLYSIS, REQUIRING USE OF OPERATING MICROSCOPE (LIST SEPARATELY IN ADDITION TO CODE FOR NEUROPLASTY) (NEUROPLASTY INCLUDES EXTERNAL NEUROLYSIS)
|
Facility
|
OP
|
$2,521.93
|
|
|
Service Code
|
CPT 64727
|
|
Hospital Revenue Code
|
490
|
| Min. Negotiated Rate |
$177.09 |
| Max. Negotiated Rate |
$2,521.93 |
| Rate for Payer: Aetna of NY Commercial |
$1,857.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$2,017.33
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$2,521.93
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$636.00
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,857.00
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$1,775.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$177.09
|
| Rate for Payer: United Healthcare Commercial |
$1,775.00
|
|
|
INTRA-ARTERIAL
|
Facility
|
OP
|
$613.00
|
|
|
Service Code
|
HCPCS 96373
|
| Hospital Charge Code |
4450102
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$204.22 |
| Max. Negotiated Rate |
$493.46 |
| Rate for Payer: Aetna of NY Commercial |
$429.10
|
| Rate for Payer: Aetna of NY Medicare |
$281.98
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$320.44
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$400.55
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$226.81
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$306.50
|
| Rate for Payer: Cash Price |
$459.75
|
| Rate for Payer: Cash Price |
$459.75
|
| Rate for Payer: Cash Price |
$459.75
|
| Rate for Payer: CDPHP Commercial |
$493.46
|
| Rate for Payer: CDPHP Medicare |
$226.81
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$490.40
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$490.40
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$490.40
|
| Rate for Payer: EmblemHealth Medicaid |
$490.40
|
| Rate for Payer: EmblemHealth Medicare |
$208.42
|
| Rate for Payer: EmblemHealth Select Care |
$441.36
|
| Rate for Payer: Fidelis Medicare |
$233.61
|
| Rate for Payer: Galaxy Health Commercial |
$398.45
|
| Rate for Payer: Hamaspik Choice Medicare |
$226.81
|
| Rate for Payer: Humana Medicare |
$226.81
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$429.10
|
| Rate for Payer: Local 1199SEIU Medicare |
$281.98
|
| Rate for Payer: MVP Health Care of NY Commercial |
$459.75
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$345.12
|
| Rate for Payer: MVP Health Care of NY Medicare |
$238.15
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$459.75
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$204.22
|
| Rate for Payer: United Healthcare Commercial |
$459.75
|
| Rate for Payer: United Healthcare Medicare |
$226.81
|
| Rate for Payer: WellCare Medicare |
$337.15
|
|
|
INTRA-ARTERIAL
|
Facility
|
IP
|
$613.00
|
|
|
Service Code
|
HCPCS 96373
|
| Hospital Charge Code |
4450102
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$398.45 |
| Max. Negotiated Rate |
$398.45 |
| Rate for Payer: Cash Price |
$459.75
|
| Rate for Payer: Galaxy Health Commercial |
$398.45
|
|
|
INTRA-ARTERIAL PHARM RX PARTICULATE
|
Facility
|
IP
|
$712.00
|
|
|
Service Code
|
HCPCS 79445
|
| Hospital Charge Code |
4210079
|
|
Hospital Revenue Code
|
342
|
| Min. Negotiated Rate |
$462.80 |
| Max. Negotiated Rate |
$462.80 |
| Rate for Payer: Cash Price |
$534.00
|
| Rate for Payer: Galaxy Health Commercial |
$462.80
|
|
|
INTRA-ARTERIAL PHARM RX PARTICULATE
|
Facility
|
OP
|
$712.00
|
|
|
Service Code
|
HCPCS 79445
|
| Hospital Charge Code |
4210079
|
|
Hospital Revenue Code
|
342
|
| Min. Negotiated Rate |
$242.08 |
| Max. Negotiated Rate |
$1,500.00 |
| Rate for Payer: Aetna of NY Commercial |
$498.40
|
| Rate for Payer: Aetna of NY Medicare |
$327.52
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$534.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$534.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$263.44
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$356.00
|
| Rate for Payer: Cash Price |
$534.00
|
| Rate for Payer: Cash Price |
$534.00
|
| Rate for Payer: CDPHP Commercial |
$573.16
|
| Rate for Payer: CDPHP Medicare |
$263.44
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$498.40
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$569.60
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$569.60
|
| Rate for Payer: EmblemHealth Medicaid |
$569.60
|
| Rate for Payer: EmblemHealth Medicare |
$242.08
|
| Rate for Payer: EmblemHealth Select Care |
$462.80
|
| Rate for Payer: Fidelis Medicare |
$271.34
|
| Rate for Payer: Galaxy Health Commercial |
$462.80
|
| Rate for Payer: Hamaspik Choice Medicare |
$263.44
|
| Rate for Payer: Humana Medicare |
$263.44
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$498.40
|
| Rate for Payer: Local 1199SEIU Medicare |
$327.52
|
| Rate for Payer: MVP Health Care of NY Commercial |
$534.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$400.86
|
| Rate for Payer: MVP Health Care of NY Medicare |
$276.61
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$1,500.00
|
| Rate for Payer: United Healthcare Commercial |
$1,500.00
|
| Rate for Payer: United Healthcare Medicare |
$263.44
|
| Rate for Payer: WellCare Medicare |
$391.60
|
|
|
INTRALIPID 20% IV FAT EMUL 250 mL, 250 mL
|
Facility
|
OP
|
$145.00
|
|
|
Service Code
|
NDC 00338051909
|
| Hospital Charge Code |
4401922
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$49.30 |
| Max. Negotiated Rate |
$116.72 |
| Rate for Payer: Aetna of NY Commercial |
$101.50
|
| Rate for Payer: Aetna of NY Medicare |
$66.70
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$108.75
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$108.75
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$53.65
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$72.50
|
| Rate for Payer: Cash Price |
$108.75
|
| Rate for Payer: CDPHP Commercial |
$116.72
|
| Rate for Payer: CDPHP Medicare |
$53.65
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$116.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$116.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$116.00
|
| Rate for Payer: EmblemHealth Medicaid |
$116.00
|
| Rate for Payer: EmblemHealth Medicare |
$49.30
|
| Rate for Payer: EmblemHealth Select Care |
$104.40
|
| Rate for Payer: Fidelis Medicare |
$55.26
|
| Rate for Payer: Galaxy Health Commercial |
$94.25
|
| Rate for Payer: Hamaspik Choice Medicare |
$53.65
|
| Rate for Payer: Humana Medicare |
$53.65
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$101.50
|
| Rate for Payer: Local 1199SEIU Medicare |
$66.70
|
| Rate for Payer: MVP Health Care of NY Commercial |
$108.75
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$81.64
|
| Rate for Payer: MVP Health Care of NY Medicare |
$56.33
|
| Rate for Payer: United Healthcare Medicare |
$53.65
|
| Rate for Payer: WellCare Medicare |
$79.75
|
|
|
INTRALIPID 20% IV FAT EMUL 250 mL, 250 mL
|
Facility
|
IP
|
$145.00
|
|
|
Service Code
|
NDC 00338051909
|
| Hospital Charge Code |
4401922
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$79.75 |
| Max. Negotiated Rate |
$94.25 |
| Rate for Payer: Cash Price |
$108.75
|
| Rate for Payer: Galaxy Health Commercial |
$94.25
|
| Rate for Payer: WellCare Medicare |
$79.75
|
|
|
INTRAORAL I&D TONGUE/FLOOR SUBMNDBLR SPACE
|
Facility
|
OP
|
$9,212.00
|
|
|
Service Code
|
HCPCS 41008
|
| Hospital Charge Code |
4601204
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$250.00 |
| Max. Negotiated Rate |
$7,415.66 |
| Rate for Payer: Aetna of NY Commercial |
$955.00
|
| Rate for Payer: Aetna of NY Medicare |
$4,237.52
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$950.93
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$1,189.18
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$3,408.44
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$4,606.00
|
| Rate for Payer: Cash Price |
$6,909.00
|
| Rate for Payer: Cash Price |
$6,909.00
|
| Rate for Payer: Cash Price |
$6,909.00
|
| Rate for Payer: Cash Price |
$6,909.00
|
| Rate for Payer: CDPHP Commercial |
$7,415.66
|
| Rate for Payer: CDPHP Medicare |
$3,408.44
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$1,182.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$7,369.60
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$7,369.60
|
| Rate for Payer: EmblemHealth Medicaid |
$7,369.60
|
| Rate for Payer: EmblemHealth Medicare |
$3,132.08
|
| Rate for Payer: EmblemHealth Select Care |
$1,064.00
|
| Rate for Payer: Fidelis Child Health Plus/Essential Plan/HARP/Medicaid |
$250.00
|
| Rate for Payer: Fidelis Medicare |
$3,510.69
|
| Rate for Payer: Galaxy Health Commercial |
$5,987.80
|
| Rate for Payer: Hamaspik Choice Medicare |
$3,408.44
|
| Rate for Payer: Humana Medicare |
$3,408.44
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$955.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$4,237.52
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,174.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$881.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$3,578.86
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$980.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$3,067.62
|
| Rate for Payer: United Healthcare Commercial |
$980.00
|
| Rate for Payer: United Healthcare Medicare |
$3,408.44
|
| Rate for Payer: WellCare Medicare |
$5,066.60
|
|
