|
M-M-R II
|
Facility
|
OP
|
$268.80
|
|
|
Service Code
|
NDC 00006468100
|
| Hospital Charge Code |
4408943
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$91.39 |
| Max. Negotiated Rate |
$216.38 |
| Rate for Payer: Aetna of NY Commercial |
$188.16
|
| Rate for Payer: Aetna of NY Medicare |
$123.65
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$201.60
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$201.60
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$99.46
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$134.40
|
| Rate for Payer: Cash Price |
$201.60
|
| Rate for Payer: CDPHP Commercial |
$216.38
|
| Rate for Payer: CDPHP Medicare |
$99.46
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$215.04
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$215.04
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$215.04
|
| Rate for Payer: EmblemHealth Medicaid |
$215.04
|
| Rate for Payer: EmblemHealth Medicare |
$91.39
|
| Rate for Payer: EmblemHealth Select Care |
$193.54
|
| Rate for Payer: Fidelis Medicare |
$102.44
|
| Rate for Payer: Galaxy Health Commercial |
$174.72
|
| Rate for Payer: Hamaspik Choice Medicare |
$99.46
|
| Rate for Payer: Humana Medicare |
$99.46
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$188.16
|
| Rate for Payer: Local 1199SEIU Medicare |
$123.65
|
| Rate for Payer: MVP Health Care of NY Commercial |
$201.60
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$151.33
|
| Rate for Payer: MVP Health Care of NY Medicare |
$104.43
|
| Rate for Payer: United Healthcare Medicare |
$99.46
|
| Rate for Payer: WellCare Medicare |
$147.84
|
|
|
M-M-R II
|
Facility
|
IP
|
$268.80
|
|
|
Service Code
|
NDC 00006468100
|
| Hospital Charge Code |
4408943
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$147.84 |
| Max. Negotiated Rate |
$174.72 |
| Rate for Payer: Cash Price |
$201.60
|
| Rate for Payer: Galaxy Health Commercial |
$174.72
|
| Rate for Payer: WellCare Medicare |
$147.84
|
|
|
MODAFINIL 100 MG TABLET 100 mg, 30 eaches
|
Facility
|
OP
|
$80.00
|
|
|
Service Code
|
NDC 65862060130
|
| Hospital Charge Code |
4401928
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$27.20 |
| Max. Negotiated Rate |
$64.40 |
| Rate for Payer: Aetna of NY Commercial |
$56.00
|
| Rate for Payer: Aetna of NY Medicare |
$36.80
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$60.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$60.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$29.60
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$40.00
|
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: CDPHP Commercial |
$64.40
|
| Rate for Payer: CDPHP Medicare |
$29.60
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$64.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$64.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$64.00
|
| Rate for Payer: EmblemHealth Medicaid |
$64.00
|
| Rate for Payer: EmblemHealth Medicare |
$27.20
|
| Rate for Payer: EmblemHealth Select Care |
$57.60
|
| Rate for Payer: Fidelis Medicare |
$30.49
|
| Rate for Payer: Galaxy Health Commercial |
$52.00
|
| Rate for Payer: Hamaspik Choice Medicare |
$29.60
|
| Rate for Payer: Humana Medicare |
$29.60
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$56.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$36.80
|
| Rate for Payer: MVP Health Care of NY Commercial |
$60.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$45.04
|
| Rate for Payer: MVP Health Care of NY Medicare |
$31.08
|
| Rate for Payer: United Healthcare Medicare |
$29.60
|
| Rate for Payer: WellCare Medicare |
$44.00
|
|
|
MODAFINIL 100 MG TABLET 100 mg, 30 eaches
|
Facility
|
IP
|
$80.00
|
|
|
Service Code
|
NDC 65862060130
|
| Hospital Charge Code |
4401928
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$44.00 |
| Max. Negotiated Rate |
$52.00 |
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Galaxy Health Commercial |
$52.00
|
| Rate for Payer: WellCare Medicare |
$44.00
|
|
|
MODERNA COVID VACCINE 25 MCG/0.25 ML 6 MO - 11Y
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
HCPCS 91321
|
| Hospital Charge Code |
4403004
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$145.92 |
| Rate for Payer: Aetna of NY Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$145.92
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$145.92
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$145.92
|
| Rate for Payer: EmblemHealth Select Care |
$145.92
|
| Rate for Payer: Galaxy Health Commercial |
$0.01
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$0.01
|
| Rate for Payer: WellCare Medicare |
$0.01
|
|
|
MODERNA COVID VACCINE 25 MCG/0.25 ML 6 MO - 11Y
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
HCPCS 91321
|
| Hospital Charge Code |
4403004
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$145.92 |
| Rate for Payer: Aetna of NY Commercial |
$0.01
|
| Rate for Payer: Aetna of NY Medicare |
$0.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$145.92
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$145.92
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$0.00
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: CDPHP Commercial |
$0.01
|
| Rate for Payer: CDPHP Medicare |
$0.00
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$145.92
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$0.01
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$0.01
|
| Rate for Payer: EmblemHealth Medicaid |
$0.01
|
| Rate for Payer: EmblemHealth Medicare |
$0.00
|
| Rate for Payer: EmblemHealth Select Care |
$145.92
|
| Rate for Payer: Fidelis Medicare |
$0.00
|
| Rate for Payer: Galaxy Health Commercial |
$0.01
|
| Rate for Payer: Hamaspik Choice Medicare |
$0.00
|
| Rate for Payer: Humana Medicare |
$0.00
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$0.01
|
| Rate for Payer: Local 1199SEIU Medicare |
$0.00
|
| Rate for Payer: MVP Health Care of NY Commercial |
$0.01
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$0.01
|
| Rate for Payer: MVP Health Care of NY Medicare |
$0.00
|
| Rate for Payer: United Healthcare Medicare |
$0.00
|
| Rate for Payer: WellCare Medicare |
$0.01
|
|
|
MODERNA COVID VACCINE 50 MCG/0.5 ML 12 Y OLDER
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
HCPCS 91322
|
| Hospital Charge Code |
4403005
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$145.92 |
| Rate for Payer: Aetna of NY Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$145.92
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$145.92
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$145.92
|
| Rate for Payer: EmblemHealth Select Care |
$145.92
|
| Rate for Payer: Galaxy Health Commercial |
$0.01
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$0.01
|
| Rate for Payer: WellCare Medicare |
$0.01
|
|
|
MODERNA COVID VACCINE 50 MCG/0.5 ML 12 Y OLDER
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
HCPCS 91322
|
| Hospital Charge Code |
4403005
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$145.92 |
| Rate for Payer: Aetna of NY Commercial |
$0.01
|
| Rate for Payer: Aetna of NY Medicare |
$0.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$145.92
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$145.92
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$0.00
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: CDPHP Commercial |
$0.01
|
| Rate for Payer: CDPHP Medicare |
$0.00
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$145.92
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$0.01
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$0.01
|
| Rate for Payer: EmblemHealth Medicaid |
$0.01
|
| Rate for Payer: EmblemHealth Medicare |
$0.00
|
| Rate for Payer: EmblemHealth Select Care |
$145.92
|
| Rate for Payer: Fidelis Medicare |
$0.00
|
| Rate for Payer: Galaxy Health Commercial |
$0.01
|
| Rate for Payer: Hamaspik Choice Medicare |
$0.00
|
| Rate for Payer: Humana Medicare |
$0.00
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$0.01
|
| Rate for Payer: Local 1199SEIU Medicare |
$0.00
|
| Rate for Payer: MVP Health Care of NY Commercial |
$0.01
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$0.01
|
| Rate for Payer: MVP Health Care of NY Medicare |
$0.00
|
| Rate for Payer: United Healthcare Medicare |
$0.00
|
| Rate for Payer: WellCare Medicare |
$0.01
|
|
|
MOD SEDATION OTHER PHYS/QHP EA
|
Facility
|
OP
|
$224.00
|
|
|
Service Code
|
HCPCS 99157
|
| Hospital Charge Code |
4601194
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$58.59 |
| Max. Negotiated Rate |
$1,189.18 |
| Rate for Payer: Aetna of NY Commercial |
$955.00
|
| Rate for Payer: Aetna of NY Medicare |
$103.04
|
| 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 |
$82.88
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$112.00
|
| Rate for Payer: Cash Price |
$168.00
|
| Rate for Payer: Cash Price |
$168.00
|
| Rate for Payer: Cash Price |
$168.00
|
| Rate for Payer: Cash Price |
$168.00
|
| Rate for Payer: CDPHP Commercial |
$180.32
|
| Rate for Payer: CDPHP Medicare |
$82.88
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$1,182.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$179.20
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$179.20
|
| Rate for Payer: EmblemHealth Medicaid |
$179.20
|
| Rate for Payer: EmblemHealth Medicare |
$76.16
|
| 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 |
$85.37
|
| Rate for Payer: Galaxy Health Commercial |
$145.60
|
| Rate for Payer: Hamaspik Choice Medicare |
$82.88
|
| Rate for Payer: Humana Medicare |
$82.88
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$955.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$103.04
|
| 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 |
$87.02
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$980.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$58.59
|
| Rate for Payer: United Healthcare Commercial |
$980.00
|
| Rate for Payer: United Healthcare Medicare |
$82.88
|
| Rate for Payer: WellCare Medicare |
$123.20
|
|
|
MOD SEDATION OTHER PHYS/QHP EA
|
Facility
|
IP
|
$224.00
|
|
|
Service Code
|
HCPCS 99157
|
| Hospital Charge Code |
4601194
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$145.60 |
| Max. Negotiated Rate |
$145.60 |
| Rate for Payer: Cash Price |
$168.00
|
| Rate for Payer: Galaxy Health Commercial |
$145.60
|
|
|
MOD SEDATION OTH PHYS/QHP <5 YRS
|
Facility
|
IP
|
$324.00
|
|
|
Service Code
|
HCPCS 99155
|
| Hospital Charge Code |
4601192
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$210.60 |
| Max. Negotiated Rate |
$210.60 |
| Rate for Payer: Cash Price |
$243.00
|
| Rate for Payer: Galaxy Health Commercial |
$210.60
|
|
|
MOD SEDATION OTH PHYS/QHP <5 YRS
|
Facility
|
OP
|
$324.00
|
|
|
Service Code
|
HCPCS 99155
|
| Hospital Charge Code |
4601192
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$81.55 |
| Max. Negotiated Rate |
$1,189.18 |
| Rate for Payer: Aetna of NY Commercial |
$955.00
|
| Rate for Payer: Aetna of NY Medicare |
$149.04
|
| 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 |
$119.88
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$162.00
|
| Rate for Payer: Cash Price |
$243.00
|
| Rate for Payer: Cash Price |
$243.00
|
| Rate for Payer: Cash Price |
$243.00
|
| Rate for Payer: Cash Price |
$243.00
|
| Rate for Payer: CDPHP Commercial |
$260.82
|
| Rate for Payer: CDPHP Medicare |
$119.88
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$1,182.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$259.20
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$259.20
|
| Rate for Payer: EmblemHealth Medicaid |
$259.20
|
| Rate for Payer: EmblemHealth Medicare |
$110.16
|
| 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 |
$123.48
|
| Rate for Payer: Galaxy Health Commercial |
$210.60
|
| Rate for Payer: Hamaspik Choice Medicare |
$119.88
|
| Rate for Payer: Humana Medicare |
$119.88
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$955.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$149.04
|
| 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 |
$125.87
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$980.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$81.55
|
| Rate for Payer: United Healthcare Commercial |
$980.00
|
| Rate for Payer: United Healthcare Medicare |
$119.88
|
| Rate for Payer: WellCare Medicare |
$178.20
|
|
|
MOD SEDATION OTH PHYS/QHP 5/>YRS
|
Facility
|
OP
|
$277.00
|
|
|
Service Code
|
HCPCS 99156
|
| Hospital Charge Code |
4601193
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$73.90 |
| Max. Negotiated Rate |
$1,189.18 |
| Rate for Payer: Aetna of NY Commercial |
$955.00
|
| Rate for Payer: Aetna of NY Medicare |
$127.42
|
| 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 |
$102.49
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$138.50
|
| Rate for Payer: Cash Price |
$207.75
|
| Rate for Payer: Cash Price |
$207.75
|
| Rate for Payer: Cash Price |
$207.75
|
| Rate for Payer: Cash Price |
$207.75
|
| Rate for Payer: CDPHP Commercial |
$222.98
|
| Rate for Payer: CDPHP Medicare |
$102.49
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$1,182.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$221.60
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$221.60
|
| Rate for Payer: EmblemHealth Medicaid |
$221.60
|
| Rate for Payer: EmblemHealth Medicare |
$94.18
|
| 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 |
$105.56
|
| Rate for Payer: Galaxy Health Commercial |
$180.05
|
| Rate for Payer: Hamaspik Choice Medicare |
$102.49
|
| Rate for Payer: Humana Medicare |
$102.49
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$955.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$127.42
|
| 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 |
$107.61
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$980.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$73.90
|
| Rate for Payer: United Healthcare Commercial |
$980.00
|
| Rate for Payer: United Healthcare Medicare |
$102.49
|
| Rate for Payer: WellCare Medicare |
$152.35
|
|
|
MOD SEDATION OTH PHYS/QHP 5/>YRS
|
Facility
|
IP
|
$277.00
|
|
|
Service Code
|
HCPCS 99156
|
| Hospital Charge Code |
4601193
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$180.05 |
| Max. Negotiated Rate |
$180.05 |
| Rate for Payer: Cash Price |
$207.75
|
| Rate for Payer: Galaxy Health Commercial |
$180.05
|
|
|
MOD SEDATION SAME PHYS/QHP <5 YRS
|
Facility
|
IP
|
$266.00
|
|
|
Service Code
|
HCPCS 99151
|
| Hospital Charge Code |
4601189
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$172.90 |
| Max. Negotiated Rate |
$172.90 |
| Rate for Payer: Cash Price |
$199.50
|
| Rate for Payer: Galaxy Health Commercial |
$172.90
|
|
|
MOD SEDATION SAME PHYS/QHP <5 YRS
|
Facility
|
OP
|
$266.00
|
|
|
Service Code
|
HCPCS 99151
|
| Hospital Charge Code |
4601189
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$23.63 |
| Max. Negotiated Rate |
$1,189.18 |
| Rate for Payer: Aetna of NY Commercial |
$955.00
|
| Rate for Payer: Aetna of NY Medicare |
$122.36
|
| 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 |
$98.42
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$133.00
|
| Rate for Payer: Cash Price |
$199.50
|
| Rate for Payer: Cash Price |
$199.50
|
| Rate for Payer: Cash Price |
$199.50
|
| Rate for Payer: Cash Price |
$199.50
|
| Rate for Payer: CDPHP Commercial |
$214.13
|
| Rate for Payer: CDPHP Medicare |
$98.42
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$1,182.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$212.80
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$212.80
|
| Rate for Payer: EmblemHealth Medicaid |
$212.80
|
| Rate for Payer: EmblemHealth Medicare |
$90.44
|
| 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 |
$101.37
|
| Rate for Payer: Galaxy Health Commercial |
$172.90
|
| Rate for Payer: Hamaspik Choice Medicare |
$98.42
|
| Rate for Payer: Humana Medicare |
$98.42
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$955.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$122.36
|
| 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 |
$103.34
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$980.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$23.63
|
| Rate for Payer: United Healthcare Commercial |
$980.00
|
| Rate for Payer: United Healthcare Medicare |
$98.42
|
| Rate for Payer: WellCare Medicare |
$146.30
|
|
|
MOD SEDATION SAME PHYS/QHP 5/>YRS
|
Facility
|
IP
|
$176.00
|
|
|
Service Code
|
HCPCS 99152
|
| Hospital Charge Code |
4601190
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$114.40 |
| Max. Negotiated Rate |
$114.40 |
| Rate for Payer: Cash Price |
$132.00
|
| Rate for Payer: Galaxy Health Commercial |
$114.40
|
|
|
MOD SEDATION SAME PHYS/QHP 5/>YRS
|
Facility
|
OP
|
$176.00
|
|
|
Service Code
|
HCPCS 99152
|
| Hospital Charge Code |
4601190
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$11.98 |
| Max. Negotiated Rate |
$1,189.18 |
| Rate for Payer: Aetna of NY Commercial |
$955.00
|
| Rate for Payer: Aetna of NY Medicare |
$80.96
|
| 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 |
$65.12
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$88.00
|
| Rate for Payer: Cash Price |
$132.00
|
| Rate for Payer: Cash Price |
$132.00
|
| Rate for Payer: Cash Price |
$132.00
|
| Rate for Payer: Cash Price |
$132.00
|
| Rate for Payer: CDPHP Commercial |
$141.68
|
| Rate for Payer: CDPHP Medicare |
$65.12
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$1,182.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$140.80
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$140.80
|
| Rate for Payer: EmblemHealth Medicaid |
$140.80
|
| Rate for Payer: EmblemHealth Medicare |
$59.84
|
| 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 |
$67.07
|
| Rate for Payer: Galaxy Health Commercial |
$114.40
|
| Rate for Payer: Hamaspik Choice Medicare |
$65.12
|
| Rate for Payer: Humana Medicare |
$65.12
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$955.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$80.96
|
| 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 |
$68.38
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$980.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$11.98
|
| Rate for Payer: United Healthcare Commercial |
$980.00
|
| Rate for Payer: United Healthcare Medicare |
$65.12
|
| Rate for Payer: WellCare Medicare |
$96.80
|
|
|
MOD SEDATION SAME PHYS/QHP EA
|
Facility
|
IP
|
$43.00
|
|
|
Service Code
|
HCPCS 99153
|
| Hospital Charge Code |
4601191
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$27.95 |
| Max. Negotiated Rate |
$27.95 |
| Rate for Payer: Cash Price |
$32.25
|
| Rate for Payer: Galaxy Health Commercial |
$27.95
|
|
|
MOD SEDATION SAME PHYS/QHP EA
|
Facility
|
OP
|
$43.00
|
|
|
Service Code
|
HCPCS 99153
|
| Hospital Charge Code |
4601191
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$11.65 |
| Max. Negotiated Rate |
$1,189.18 |
| Rate for Payer: Aetna of NY Commercial |
$955.00
|
| Rate for Payer: Aetna of NY Medicare |
$19.78
|
| 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 |
$15.91
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$21.50
|
| Rate for Payer: Cash Price |
$32.25
|
| Rate for Payer: Cash Price |
$32.25
|
| Rate for Payer: Cash Price |
$32.25
|
| Rate for Payer: Cash Price |
$32.25
|
| Rate for Payer: CDPHP Commercial |
$34.62
|
| Rate for Payer: CDPHP Medicare |
$15.91
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$1,182.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$34.40
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$34.40
|
| Rate for Payer: EmblemHealth Medicaid |
$34.40
|
| Rate for Payer: EmblemHealth Medicare |
$14.62
|
| 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 |
$16.39
|
| Rate for Payer: Galaxy Health Commercial |
$27.95
|
| Rate for Payer: Hamaspik Choice Medicare |
$15.91
|
| Rate for Payer: Humana Medicare |
$15.91
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$955.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$19.78
|
| 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 |
$16.71
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$980.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$11.65
|
| Rate for Payer: United Healthcare Commercial |
$980.00
|
| Rate for Payer: United Healthcare Medicare |
$15.91
|
| Rate for Payer: WellCare Medicare |
$23.65
|
|
|
MOD SED SAME PHYS/QHP EACH ADDL 15 MINS
|
Facility
|
IP
|
$45.00
|
|
|
Service Code
|
HCPCS 99153
|
| Hospital Charge Code |
4120031
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$29.25 |
| Max. Negotiated Rate |
$29.25 |
| Rate for Payer: Cash Price |
$33.75
|
| Rate for Payer: Galaxy Health Commercial |
$29.25
|
|
|
MOD SED SAME PHYS/QHP EACH ADDL 15 MINS
|
Facility
|
OP
|
$45.00
|
|
|
Service Code
|
HCPCS 99153
|
| Hospital Charge Code |
4120031
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$11.65 |
| Max. Negotiated Rate |
$36.22 |
| Rate for Payer: Aetna of NY Commercial |
$31.50
|
| Rate for Payer: Aetna of NY Medicare |
$20.70
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$33.75
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$33.75
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$16.65
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$22.50
|
| Rate for Payer: Cash Price |
$33.75
|
| Rate for Payer: Cash Price |
$33.75
|
| Rate for Payer: CDPHP Commercial |
$36.22
|
| Rate for Payer: CDPHP Medicare |
$16.65
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$36.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$36.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$36.00
|
| Rate for Payer: EmblemHealth Medicaid |
$36.00
|
| Rate for Payer: EmblemHealth Medicare |
$15.30
|
| Rate for Payer: EmblemHealth Select Care |
$32.40
|
| Rate for Payer: Fidelis Medicare |
$17.15
|
| Rate for Payer: Galaxy Health Commercial |
$29.25
|
| Rate for Payer: Hamaspik Choice Medicare |
$16.65
|
| Rate for Payer: Humana Medicare |
$16.65
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$31.50
|
| Rate for Payer: Local 1199SEIU Medicare |
$20.70
|
| Rate for Payer: MVP Health Care of NY Commercial |
$33.75
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$25.34
|
| Rate for Payer: MVP Health Care of NY Medicare |
$17.48
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$11.65
|
| Rate for Payer: United Healthcare Medicare |
$16.65
|
| Rate for Payer: WellCare Medicare |
$24.75
|
|
|
MOD SED SAME PHYS/QHP INITIAL 15 MINS 5/> YRS
|
Facility
|
IP
|
$74.00
|
|
|
Service Code
|
HCPCS 99152
|
| Hospital Charge Code |
4120030
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$48.10 |
| Max. Negotiated Rate |
$48.10 |
| Rate for Payer: Cash Price |
$55.50
|
| Rate for Payer: Galaxy Health Commercial |
$48.10
|
|
|
MOD SED SAME PHYS/QHP INITIAL 15 MINS 5/> YRS
|
Facility
|
OP
|
$74.00
|
|
|
Service Code
|
HCPCS 99152
|
| Hospital Charge Code |
4120030
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$11.98 |
| Max. Negotiated Rate |
$59.57 |
| Rate for Payer: Aetna of NY Commercial |
$51.80
|
| Rate for Payer: Aetna of NY Medicare |
$34.04
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$55.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$55.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$27.38
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$37.00
|
| Rate for Payer: Cash Price |
$55.50
|
| Rate for Payer: Cash Price |
$55.50
|
| Rate for Payer: CDPHP Commercial |
$59.57
|
| Rate for Payer: CDPHP Medicare |
$27.38
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$59.20
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$59.20
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$59.20
|
| Rate for Payer: EmblemHealth Medicaid |
$59.20
|
| Rate for Payer: EmblemHealth Medicare |
$25.16
|
| Rate for Payer: EmblemHealth Select Care |
$53.28
|
| Rate for Payer: Fidelis Medicare |
$28.20
|
| Rate for Payer: Galaxy Health Commercial |
$48.10
|
| Rate for Payer: Hamaspik Choice Medicare |
$27.38
|
| Rate for Payer: Humana Medicare |
$27.38
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$51.80
|
| Rate for Payer: Local 1199SEIU Medicare |
$34.04
|
| Rate for Payer: MVP Health Care of NY Commercial |
$55.50
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$41.66
|
| Rate for Payer: MVP Health Care of NY Medicare |
$28.75
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$11.98
|
| Rate for Payer: United Healthcare Medicare |
$27.38
|
| Rate for Payer: WellCare Medicare |
$40.70
|
|
|
MONOSOF 6/0 18IN BLACK P-24
|
Facility
|
IP
|
$36.00
|
|
| Hospital Charge Code |
4472081
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$23.40 |
| Max. Negotiated Rate |
$23.40 |
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Galaxy Health Commercial |
$23.40
|
|
