|
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 |
$33.60 |
| Max. Negotiated Rate |
$1,234.00 |
| Rate for Payer: Aetna of NY Commercial |
$1,000.00
|
| Rate for Payer: Aetna of NY Medicare |
$103.04
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$89.60
|
| 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 Medicare |
$82.88
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$1,206.00
|
| 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 |
$1,085.00
|
| Rate for Payer: Fidelis Medicare |
$89.60
|
| Rate for Payer: Galaxy Health Commercial |
$145.60
|
| Rate for Payer: Hamaspik Choice Medicare |
$89.60
|
| Rate for Payer: Humana Medicare |
$89.60
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,000.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$103.04
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,234.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$925.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$94.08
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$1,009.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$33.60
|
| Rate for Payer: United Healthcare Commercial |
$1,009.00
|
| Rate for Payer: United Healthcare Medicare |
$89.60
|
| Rate for Payer: WellCare Medicare |
$123.20
|
|
|
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 |
$48.60 |
| Max. Negotiated Rate |
$1,234.00 |
| Rate for Payer: Aetna of NY Commercial |
$1,000.00
|
| Rate for Payer: Aetna of NY Medicare |
$149.04
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$129.60
|
| 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 Medicare |
$119.88
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$1,206.00
|
| 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 |
$1,085.00
|
| Rate for Payer: Fidelis Medicare |
$129.60
|
| Rate for Payer: Galaxy Health Commercial |
$210.60
|
| Rate for Payer: Hamaspik Choice Medicare |
$129.60
|
| Rate for Payer: Humana Medicare |
$129.60
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,000.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$149.04
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,234.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$925.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$136.08
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$1,009.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$48.60
|
| Rate for Payer: United Healthcare Commercial |
$1,009.00
|
| Rate for Payer: United Healthcare Medicare |
$129.60
|
| Rate for Payer: WellCare Medicare |
$178.20
|
|
|
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 OTH PHYS/QHP 5/>YRS
|
Facility
|
OP
|
$277.00
|
|
|
Service Code
|
HCPCS 99156
|
| Hospital Charge Code |
4601193
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$41.55 |
| Max. Negotiated Rate |
$1,234.00 |
| Rate for Payer: Aetna of NY Commercial |
$1,000.00
|
| Rate for Payer: Aetna of NY Medicare |
$127.42
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$110.80
|
| 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 Medicare |
$102.49
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$1,206.00
|
| 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 |
$1,085.00
|
| Rate for Payer: Fidelis Medicare |
$110.80
|
| Rate for Payer: Galaxy Health Commercial |
$180.05
|
| Rate for Payer: Hamaspik Choice Medicare |
$110.80
|
| Rate for Payer: Humana Medicare |
$110.80
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,000.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$127.42
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,234.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$925.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$116.34
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$1,009.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$41.55
|
| Rate for Payer: United Healthcare Commercial |
$1,009.00
|
| Rate for Payer: United Healthcare Medicare |
$110.80
|
| Rate for Payer: WellCare Medicare |
$152.35
|
|
|
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 |
$39.90 |
| Max. Negotiated Rate |
$1,234.00 |
| Rate for Payer: Aetna of NY Commercial |
$1,000.00
|
| Rate for Payer: Aetna of NY Medicare |
$122.36
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$106.40
|
| 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 Medicare |
$98.42
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$1,206.00
|
| 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 |
$1,085.00
|
| Rate for Payer: Fidelis Medicare |
$106.40
|
| Rate for Payer: Galaxy Health Commercial |
$172.90
|
| Rate for Payer: Hamaspik Choice Medicare |
$106.40
|
| Rate for Payer: Humana Medicare |
$106.40
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,000.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$122.36
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,234.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$925.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$111.72
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$1,009.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$39.90
|
| Rate for Payer: United Healthcare Commercial |
$1,009.00
|
| Rate for Payer: United Healthcare Medicare |
$106.40
|
| Rate for Payer: WellCare Medicare |
$146.30
|
|
|
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 |
$26.40 |
| Max. Negotiated Rate |
$1,234.00 |
| Rate for Payer: Aetna of NY Commercial |
$1,000.00
|
| Rate for Payer: Aetna of NY Medicare |
$80.96
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$70.40
|
| 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 Medicare |
$65.12
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$1,206.00
|
| 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 |
$1,085.00
|
| Rate for Payer: Fidelis Medicare |
$70.40
|
| Rate for Payer: Galaxy Health Commercial |
$114.40
|
| Rate for Payer: Hamaspik Choice Medicare |
$70.40
|
| Rate for Payer: Humana Medicare |
$70.40
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,000.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$80.96
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,234.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$925.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$73.92
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$1,009.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$26.40
|
| Rate for Payer: United Healthcare Commercial |
$1,009.00
|
| Rate for Payer: United Healthcare Medicare |
$70.40
|
| Rate for Payer: WellCare Medicare |
$96.80
|
|
|
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 EA
|
Facility
|
OP
|
$43.00
|
|
|
Service Code
|
HCPCS 99153
|
| Hospital Charge Code |
4601191
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$6.45 |
| Max. Negotiated Rate |
$1,234.00 |
| Rate for Payer: Aetna of NY Commercial |
$1,000.00
|
| Rate for Payer: Aetna of NY Medicare |
$19.78
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$17.20
|
| 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 Medicare |
$15.91
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$1,206.00
|
| 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 |
$1,085.00
|
| Rate for Payer: Fidelis Medicare |
$17.20
|
| Rate for Payer: Galaxy Health Commercial |
$27.95
|
| Rate for Payer: Hamaspik Choice Medicare |
$17.20
|
| Rate for Payer: Humana Medicare |
$17.20
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,000.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$19.78
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,234.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$925.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$18.06
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$1,009.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$6.45
|
| Rate for Payer: United Healthcare Commercial |
$1,009.00
|
| Rate for Payer: United Healthcare Medicare |
$17.20
|
| Rate for Payer: WellCare Medicare |
$23.65
|
|
|
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 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 |
$6.75 |
| Max. Negotiated Rate |
$36.00 |
| 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) Medicare |
$18.00
|
| Rate for Payer: Cash Price |
$33.75
|
| 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 |
$18.00
|
| Rate for Payer: Galaxy Health Commercial |
$29.25
|
| Rate for Payer: Hamaspik Choice Medicare |
$18.00
|
| Rate for Payer: Humana Medicare |
$18.00
|
| 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 |
$18.90
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$6.75
|
| Rate for Payer: United Healthcare Medicare |
$18.00
|
| Rate for Payer: WellCare Medicare |
$24.75
|
|
|
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 INITIAL 15 MINS 5/> YRS
|
Facility
|
OP
|
$169.00
|
|
|
Service Code
|
HCPCS 99152
|
| Hospital Charge Code |
4120030
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$25.35 |
| Max. Negotiated Rate |
$135.20 |
| Rate for Payer: Aetna of NY Commercial |
$118.30
|
| Rate for Payer: Aetna of NY Medicare |
$77.74
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$67.60
|
| Rate for Payer: Cash Price |
$126.75
|
| Rate for Payer: CDPHP Medicare |
$62.53
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$135.20
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$135.20
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$135.20
|
| Rate for Payer: EmblemHealth Medicaid |
$135.20
|
| Rate for Payer: EmblemHealth Medicare |
$57.46
|
| Rate for Payer: EmblemHealth Select Care |
$121.68
|
| Rate for Payer: Fidelis Medicare |
$67.60
|
| Rate for Payer: Galaxy Health Commercial |
$109.85
|
| Rate for Payer: Hamaspik Choice Medicare |
$67.60
|
| Rate for Payer: Humana Medicare |
$67.60
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$118.30
|
| Rate for Payer: Local 1199SEIU Medicare |
$77.74
|
| Rate for Payer: MVP Health Care of NY Commercial |
$126.75
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$95.15
|
| Rate for Payer: MVP Health Care of NY Medicare |
$70.98
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$25.35
|
| Rate for Payer: United Healthcare Medicare |
$67.60
|
| Rate for Payer: WellCare Medicare |
$92.95
|
|
|
MOD SED SAME PHYS/QHP INITIAL 15 MINS 5/> YRS
|
Facility
|
IP
|
$169.00
|
|
|
Service Code
|
HCPCS 99152
|
| Hospital Charge Code |
4120030
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$109.85 |
| Max. Negotiated Rate |
$109.85 |
| Rate for Payer: Cash Price |
$126.75
|
| Rate for Payer: Galaxy Health Commercial |
$109.85
|
|
|
MONOSOF 6/0 18IN BLACK P-24
|
Facility
|
IP
|
$37.08
|
|
| Hospital Charge Code |
4472081
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$24.10 |
| Max. Negotiated Rate |
$24.10 |
| Rate for Payer: Cash Price |
$27.81
|
| Rate for Payer: Galaxy Health Commercial |
$24.10
|
|
|
MONOSOF 6/0 18IN BLACK P-24
|
Facility
|
OP
|
$37.08
|
|
| Hospital Charge Code |
4472081
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$5.56 |
| Max. Negotiated Rate |
$29.66 |
| Rate for Payer: Aetna of NY Commercial |
$25.96
|
| Rate for Payer: Aetna of NY Medicare |
$17.06
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$14.83
|
| Rate for Payer: Cash Price |
$27.81
|
| Rate for Payer: CDPHP Medicare |
$13.72
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$29.66
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$29.66
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$29.66
|
| Rate for Payer: EmblemHealth Medicaid |
$29.66
|
| Rate for Payer: EmblemHealth Medicare |
$12.61
|
| Rate for Payer: EmblemHealth Select Care |
$26.70
|
| Rate for Payer: Fidelis Medicare |
$14.83
|
| Rate for Payer: Galaxy Health Commercial |
$24.10
|
| Rate for Payer: Hamaspik Choice Medicare |
$14.83
|
| Rate for Payer: Humana Medicare |
$14.83
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$25.96
|
| Rate for Payer: Local 1199SEIU Medicare |
$17.06
|
| Rate for Payer: MVP Health Care of NY Commercial |
$27.81
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$20.88
|
| Rate for Payer: MVP Health Care of NY Medicare |
$15.57
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$5.56
|
| Rate for Payer: United Healthcare Medicare |
$14.83
|
| Rate for Payer: WellCare Medicare |
$20.39
|
|
|
MONTELUKAST SODIUM 10MG TABS 100 EA
|
Facility
|
IP
|
$17.51
|
|
|
Service Code
|
NDC 68084087511
|
| Hospital Charge Code |
4400704
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.63 |
| Max. Negotiated Rate |
$11.38 |
| Rate for Payer: Cash Price |
$13.13
|
| Rate for Payer: Galaxy Health Commercial |
$11.38
|
| Rate for Payer: WellCare Medicare |
$9.63
|
|
|
MONTELUKAST SODIUM 10MG TABS 100 EA
|
Facility
|
OP
|
$17.51
|
|
|
Service Code
|
NDC 68084087511
|
| Hospital Charge Code |
4400704
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.63 |
| Max. Negotiated Rate |
$14.01 |
| Rate for Payer: Aetna of NY Commercial |
$12.26
|
| Rate for Payer: Aetna of NY Medicare |
$8.05
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$7.00
|
| Rate for Payer: Cash Price |
$13.13
|
| Rate for Payer: CDPHP Medicare |
$6.48
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$14.01
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$14.01
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$14.01
|
| Rate for Payer: EmblemHealth Medicaid |
$14.01
|
| Rate for Payer: EmblemHealth Medicare |
$5.95
|
| Rate for Payer: EmblemHealth Select Care |
$12.61
|
| Rate for Payer: Fidelis Medicare |
$7.00
|
| Rate for Payer: Galaxy Health Commercial |
$11.38
|
| Rate for Payer: Hamaspik Choice Medicare |
$7.00
|
| Rate for Payer: Humana Medicare |
$7.00
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$12.26
|
| Rate for Payer: Local 1199SEIU Medicare |
$8.05
|
| Rate for Payer: MVP Health Care of NY Commercial |
$13.13
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$9.86
|
| Rate for Payer: MVP Health Care of NY Medicare |
$7.35
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$2.63
|
| Rate for Payer: United Healthcare Medicare |
$7.00
|
| Rate for Payer: WellCare Medicare |
$9.63
|
|
|
morphine SULFATE 10 MG/ML VIAL 10 mg, 1 mL
|
Facility
|
IP
|
$15.00
|
|
|
Service Code
|
NDC 641612701
|
| Hospital Charge Code |
4401328
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.25 |
| Max. Negotiated Rate |
$9.75 |
| Rate for Payer: Cash Price |
$11.25
|
| Rate for Payer: Galaxy Health Commercial |
$9.75
|
| Rate for Payer: WellCare Medicare |
$8.25
|
|
|
morphine SULFATE 10 MG/ML VIAL 10 mg, 1 mL
|
Facility
|
OP
|
$15.00
|
|
|
Service Code
|
NDC 641612701
|
| Hospital Charge Code |
4401328
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.25 |
| Max. Negotiated Rate |
$12.00 |
| Rate for Payer: Aetna of NY Commercial |
$10.50
|
| Rate for Payer: Aetna of NY Medicare |
$6.90
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$6.00
|
| Rate for Payer: Cash Price |
$11.25
|
| Rate for Payer: CDPHP Medicare |
$5.55
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$12.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$12.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$12.00
|
| Rate for Payer: EmblemHealth Medicaid |
$12.00
|
| Rate for Payer: EmblemHealth Medicare |
$5.10
|
| Rate for Payer: EmblemHealth Select Care |
$10.80
|
| Rate for Payer: Fidelis Medicare |
$6.00
|
| Rate for Payer: Galaxy Health Commercial |
$9.75
|
| Rate for Payer: Hamaspik Choice Medicare |
$6.00
|
| Rate for Payer: Humana Medicare |
$6.00
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$10.50
|
| Rate for Payer: Local 1199SEIU Medicare |
$6.90
|
| Rate for Payer: MVP Health Care of NY Commercial |
$11.25
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$8.45
|
| Rate for Payer: MVP Health Care of NY Medicare |
$6.30
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$2.25
|
| Rate for Payer: United Healthcare Medicare |
$6.00
|
| Rate for Payer: WellCare Medicare |
$8.25
|
|
|
MORPHINE SULFATE 15MG TABS 10X10EA
|
Facility
|
OP
|
$6.18
|
|
|
Service Code
|
NDC 406831562
|
| Hospital Charge Code |
4400524
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.93 |
| Max. Negotiated Rate |
$4.94 |
| 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) Medicare |
$2.47
|
| Rate for Payer: Cash Price |
$4.64
|
| 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 |
$2.47
|
| Rate for Payer: Galaxy Health Commercial |
$4.02
|
| Rate for Payer: Hamaspik Choice Medicare |
$2.47
|
| Rate for Payer: Humana Medicare |
$2.47
|
| 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 |
$4.63
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$3.48
|
| Rate for Payer: MVP Health Care of NY Medicare |
$2.60
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$0.93
|
| Rate for Payer: United Healthcare Medicare |
$2.47
|
| Rate for Payer: WellCare Medicare |
$3.40
|
|
|
MORPHINE SULFATE 15MG TABS 10X10EA
|
Facility
|
IP
|
$6.18
|
|
|
Service Code
|
NDC 406831562
|
| Hospital Charge Code |
4400524
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.40 |
| Max. Negotiated Rate |
$4.02 |
| Rate for Payer: Cash Price |
$4.64
|
| Rate for Payer: Galaxy Health Commercial |
$4.02
|
| Rate for Payer: WellCare Medicare |
$3.40
|
|
|
morphine SULFATE 2 MG/ML VIAL 2 mg, 1 mL
|
Facility
|
IP
|
$12.00
|
|
|
Service Code
|
NDC 63323045201
|
| Hospital Charge Code |
4401346
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.60 |
| Max. Negotiated Rate |
$7.80 |
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Galaxy Health Commercial |
$7.80
|
| Rate for Payer: WellCare Medicare |
$6.60
|
|
|
morphine SULFATE 2 MG/ML VIAL 2 mg, 1 mL
|
Facility
|
OP
|
$12.00
|
|
|
Service Code
|
NDC 63323045201
|
| Hospital Charge Code |
4401346
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.80 |
| Max. Negotiated Rate |
$9.60 |
| Rate for Payer: Aetna of NY Commercial |
$8.40
|
| Rate for Payer: Aetna of NY Medicare |
$5.52
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$4.80
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: CDPHP Medicare |
$4.44
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$9.60
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$9.60
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$9.60
|
| Rate for Payer: EmblemHealth Medicaid |
$9.60
|
| Rate for Payer: EmblemHealth Medicare |
$4.08
|
| Rate for Payer: EmblemHealth Select Care |
$8.64
|
| Rate for Payer: Fidelis Medicare |
$4.80
|
| Rate for Payer: Galaxy Health Commercial |
$7.80
|
| Rate for Payer: Hamaspik Choice Medicare |
$4.80
|
| Rate for Payer: Humana Medicare |
$4.80
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$8.40
|
| Rate for Payer: Local 1199SEIU Medicare |
$5.52
|
| Rate for Payer: MVP Health Care of NY Commercial |
$9.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$6.76
|
| Rate for Payer: MVP Health Care of NY Medicare |
$5.04
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$1.80
|
| Rate for Payer: United Healthcare Medicare |
$4.80
|
| Rate for Payer: WellCare Medicare |
$6.60
|
|
