|
NYSTATIN 100MU/GM POWD 15 GM
|
Facility
|
OP
|
$115.62
|
|
|
Service Code
|
NDC 832046515
|
| Hospital Charge Code |
4400578
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.34 |
| Max. Negotiated Rate |
$92.50 |
| Rate for Payer: Aetna of NY Commercial |
$80.93
|
| Rate for Payer: Aetna of NY Medicare |
$53.19
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$46.25
|
| Rate for Payer: Cash Price |
$86.72
|
| Rate for Payer: CDPHP Medicare |
$42.78
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$92.50
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$92.50
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$92.50
|
| Rate for Payer: EmblemHealth Medicaid |
$92.50
|
| Rate for Payer: EmblemHealth Medicare |
$39.31
|
| Rate for Payer: EmblemHealth Select Care |
$83.25
|
| Rate for Payer: Fidelis Medicare |
$46.25
|
| Rate for Payer: Galaxy Health Commercial |
$75.15
|
| Rate for Payer: Hamaspik Choice Medicare |
$46.25
|
| Rate for Payer: Humana Medicare |
$46.25
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$80.93
|
| Rate for Payer: Local 1199SEIU Medicare |
$53.19
|
| Rate for Payer: MVP Health Care of NY Commercial |
$86.72
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$65.09
|
| Rate for Payer: MVP Health Care of NY Medicare |
$48.56
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$17.34
|
| Rate for Payer: United Healthcare Medicare |
$46.25
|
| Rate for Payer: WellCare Medicare |
$63.59
|
|
|
NYSTATIN 100MU/GM POWD 15 GM
|
Facility
|
IP
|
$115.62
|
|
|
Service Code
|
NDC 832046515
|
| Hospital Charge Code |
4400578
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$63.59 |
| Max. Negotiated Rate |
$75.15 |
| Rate for Payer: Cash Price |
$86.72
|
| Rate for Payer: Galaxy Health Commercial |
$75.15
|
| Rate for Payer: WellCare Medicare |
$63.59
|
|
|
NYSTATIN OINTMENT 30 GRAMS
|
Facility
|
OP
|
$77.77
|
|
|
Service Code
|
NDC 168000730
|
| Hospital Charge Code |
4409149
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.67 |
| Max. Negotiated Rate |
$62.22 |
| Rate for Payer: Aetna of NY Commercial |
$54.44
|
| Rate for Payer: Aetna of NY Medicare |
$35.77
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$31.11
|
| Rate for Payer: Cash Price |
$58.33
|
| Rate for Payer: CDPHP Medicare |
$28.77
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$62.22
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$62.22
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$62.22
|
| Rate for Payer: EmblemHealth Medicaid |
$62.22
|
| Rate for Payer: EmblemHealth Medicare |
$26.44
|
| Rate for Payer: EmblemHealth Select Care |
$55.99
|
| Rate for Payer: Fidelis Medicare |
$31.11
|
| Rate for Payer: Galaxy Health Commercial |
$50.55
|
| Rate for Payer: Hamaspik Choice Medicare |
$31.11
|
| Rate for Payer: Humana Medicare |
$31.11
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$54.44
|
| Rate for Payer: Local 1199SEIU Medicare |
$35.77
|
| Rate for Payer: MVP Health Care of NY Commercial |
$58.33
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$43.78
|
| Rate for Payer: MVP Health Care of NY Medicare |
$32.66
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$11.67
|
| Rate for Payer: United Healthcare Medicare |
$31.11
|
| Rate for Payer: WellCare Medicare |
$42.77
|
|
|
NYSTATIN OINTMENT 30 GRAMS
|
Facility
|
IP
|
$77.77
|
|
|
Service Code
|
NDC 168000730
|
| Hospital Charge Code |
4409149
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$42.77 |
| Max. Negotiated Rate |
$50.55 |
| Rate for Payer: Cash Price |
$58.33
|
| Rate for Payer: Galaxy Health Commercial |
$50.55
|
| Rate for Payer: WellCare Medicare |
$42.77
|
|
|
NYSTATIN POWDER 30 GRAMS
|
Facility
|
IP
|
$226.60
|
|
|
Service Code
|
NDC 832046530
|
| Hospital Charge Code |
4409148
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$124.63 |
| Max. Negotiated Rate |
$147.29 |
| Rate for Payer: Cash Price |
$169.95
|
| Rate for Payer: Galaxy Health Commercial |
$147.29
|
| Rate for Payer: WellCare Medicare |
$124.63
|
|
|
NYSTATIN POWDER 30 GRAMS
|
Facility
|
OP
|
$226.60
|
|
|
Service Code
|
NDC 832046530
|
| Hospital Charge Code |
4409148
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$33.99 |
| Max. Negotiated Rate |
$181.28 |
| Rate for Payer: Aetna of NY Commercial |
$158.62
|
| Rate for Payer: Aetna of NY Medicare |
$104.24
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$90.64
|
| Rate for Payer: Cash Price |
$169.95
|
| Rate for Payer: CDPHP Medicare |
$83.84
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$181.28
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$181.28
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$181.28
|
| Rate for Payer: EmblemHealth Medicaid |
$181.28
|
| Rate for Payer: EmblemHealth Medicare |
$77.04
|
| Rate for Payer: EmblemHealth Select Care |
$163.15
|
| Rate for Payer: Fidelis Medicare |
$90.64
|
| Rate for Payer: Galaxy Health Commercial |
$147.29
|
| Rate for Payer: Hamaspik Choice Medicare |
$90.64
|
| Rate for Payer: Humana Medicare |
$90.64
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$158.62
|
| Rate for Payer: Local 1199SEIU Medicare |
$104.24
|
| Rate for Payer: MVP Health Care of NY Commercial |
$169.95
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$127.58
|
| Rate for Payer: MVP Health Care of NY Medicare |
$95.17
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$33.99
|
| Rate for Payer: United Healthcare Medicare |
$90.64
|
| Rate for Payer: WellCare Medicare |
$124.63
|
|
|
NYSTATIN/TRIAMCINOLONE 100MU-0.1%/GM CRM
|
Facility
|
OP
|
$345.82
|
|
|
Service Code
|
NDC 51672126301
|
| Hospital Charge Code |
4400582
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$51.87 |
| Max. Negotiated Rate |
$276.66 |
| Rate for Payer: Aetna of NY Commercial |
$242.07
|
| Rate for Payer: Aetna of NY Medicare |
$159.08
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$138.33
|
| Rate for Payer: Cash Price |
$259.36
|
| Rate for Payer: CDPHP Medicare |
$127.95
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$276.66
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$276.66
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$276.66
|
| Rate for Payer: EmblemHealth Medicaid |
$276.66
|
| Rate for Payer: EmblemHealth Medicare |
$117.58
|
| Rate for Payer: EmblemHealth Select Care |
$248.99
|
| Rate for Payer: Fidelis Medicare |
$138.33
|
| Rate for Payer: Galaxy Health Commercial |
$224.78
|
| Rate for Payer: Hamaspik Choice Medicare |
$138.33
|
| Rate for Payer: Humana Medicare |
$138.33
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$242.07
|
| Rate for Payer: Local 1199SEIU Medicare |
$159.08
|
| Rate for Payer: MVP Health Care of NY Commercial |
$259.37
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$194.70
|
| Rate for Payer: MVP Health Care of NY Medicare |
$145.24
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$51.87
|
| Rate for Payer: United Healthcare Medicare |
$138.33
|
| Rate for Payer: WellCare Medicare |
$190.20
|
|
|
NYSTATIN/TRIAMCINOLONE 100MU-0.1%/GM CRM
|
Facility
|
IP
|
$345.82
|
|
|
Service Code
|
NDC 51672126301
|
| Hospital Charge Code |
4400582
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$190.20 |
| Max. Negotiated Rate |
$224.78 |
| Rate for Payer: Cash Price |
$259.36
|
| Rate for Payer: Galaxy Health Commercial |
$224.78
|
| Rate for Payer: WellCare Medicare |
$190.20
|
|
|
O2 SENSOR ADULT
|
Facility
|
IP
|
$32.96
|
|
| Hospital Charge Code |
4479162
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$21.42 |
| Max. Negotiated Rate |
$21.42 |
| Rate for Payer: Cash Price |
$24.72
|
| Rate for Payer: Galaxy Health Commercial |
$21.42
|
|
|
O2 SENSOR ADULT
|
Facility
|
OP
|
$32.96
|
|
| Hospital Charge Code |
4479162
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$4.94 |
| Max. Negotiated Rate |
$26.37 |
| Rate for Payer: Aetna of NY Commercial |
$23.07
|
| Rate for Payer: Aetna of NY Medicare |
$15.16
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$13.18
|
| Rate for Payer: Cash Price |
$24.72
|
| Rate for Payer: CDPHP Medicare |
$12.20
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$26.37
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$26.37
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$26.37
|
| Rate for Payer: EmblemHealth Medicaid |
$26.37
|
| Rate for Payer: EmblemHealth Medicare |
$11.21
|
| Rate for Payer: EmblemHealth Select Care |
$23.73
|
| Rate for Payer: Fidelis Medicare |
$13.18
|
| Rate for Payer: Galaxy Health Commercial |
$21.42
|
| Rate for Payer: Hamaspik Choice Medicare |
$13.18
|
| Rate for Payer: Humana Medicare |
$13.18
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$23.07
|
| Rate for Payer: Local 1199SEIU Medicare |
$15.16
|
| Rate for Payer: MVP Health Care of NY Commercial |
$24.72
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$18.56
|
| Rate for Payer: MVP Health Care of NY Medicare |
$13.84
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$4.94
|
| Rate for Payer: United Healthcare Medicare |
$13.18
|
| Rate for Payer: WellCare Medicare |
$18.13
|
|
|
OBSERVATION ROOM 1 HR-EMER RM
|
Facility
|
IP
|
$146.26
|
|
|
Service Code
|
HCPCS G0378
|
| Hospital Charge Code |
4760002
|
|
Hospital Revenue Code
|
762
|
| Min. Negotiated Rate |
$95.07 |
| Max. Negotiated Rate |
$95.07 |
| Rate for Payer: Cash Price |
$109.70
|
| Rate for Payer: Galaxy Health Commercial |
$95.07
|
|
|
OBSERVATION ROOM 1 HR-EMER RM
|
Facility
|
OP
|
$146.26
|
|
|
Service Code
|
HCPCS G0378
|
| Hospital Charge Code |
4760002
|
|
Hospital Revenue Code
|
762
|
| Min. Negotiated Rate |
$21.94 |
| Max. Negotiated Rate |
$3,588.00 |
| Rate for Payer: Aetna of NY Commercial |
$3,588.00
|
| Rate for Payer: Aetna of NY Medicare |
$67.28
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$58.50
|
| Rate for Payer: Cash Price |
$109.70
|
| Rate for Payer: Cash Price |
$109.70
|
| Rate for Payer: Cash Price |
$109.70
|
| Rate for Payer: CDPHP Medicare |
$54.12
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$2,700.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$117.01
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$117.01
|
| Rate for Payer: EmblemHealth Medicaid |
$117.01
|
| Rate for Payer: EmblemHealth Medicare |
$49.73
|
| Rate for Payer: EmblemHealth Select Care |
$2,430.00
|
| Rate for Payer: Fidelis Medicare |
$58.50
|
| Rate for Payer: Galaxy Health Commercial |
$95.07
|
| Rate for Payer: Hamaspik Choice Medicare |
$58.50
|
| Rate for Payer: Humana Medicare |
$58.50
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$3,588.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$67.28
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,786.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$2,090.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$61.43
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$3,228.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$21.94
|
| Rate for Payer: United Healthcare Commercial |
$3,228.00
|
| Rate for Payer: United Healthcare Medicare |
$58.50
|
| Rate for Payer: WellCare Medicare |
$80.44
|
|
|
OBSERVATION ROOM 1 HR-MED SURG
|
Facility
|
IP
|
$146.26
|
|
|
Service Code
|
HCPCS G0378
|
| Hospital Charge Code |
4760003
|
|
Hospital Revenue Code
|
762
|
| Min. Negotiated Rate |
$95.07 |
| Max. Negotiated Rate |
$95.07 |
| Rate for Payer: Cash Price |
$109.70
|
| Rate for Payer: Galaxy Health Commercial |
$95.07
|
|
|
OBSERVATION ROOM 1 HR-MED SURG
|
Facility
|
OP
|
$146.26
|
|
|
Service Code
|
HCPCS G0378
|
| Hospital Charge Code |
4760003
|
|
Hospital Revenue Code
|
762
|
| Min. Negotiated Rate |
$21.94 |
| Max. Negotiated Rate |
$3,588.00 |
| Rate for Payer: Aetna of NY Commercial |
$3,588.00
|
| Rate for Payer: Aetna of NY Medicare |
$67.28
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$58.50
|
| Rate for Payer: Cash Price |
$109.70
|
| Rate for Payer: Cash Price |
$109.70
|
| Rate for Payer: Cash Price |
$109.70
|
| Rate for Payer: CDPHP Medicare |
$54.12
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$2,700.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$117.01
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$117.01
|
| Rate for Payer: EmblemHealth Medicaid |
$117.01
|
| Rate for Payer: EmblemHealth Medicare |
$49.73
|
| Rate for Payer: EmblemHealth Select Care |
$2,430.00
|
| Rate for Payer: Fidelis Medicare |
$58.50
|
| Rate for Payer: Galaxy Health Commercial |
$95.07
|
| Rate for Payer: Hamaspik Choice Medicare |
$58.50
|
| Rate for Payer: Humana Medicare |
$58.50
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$3,588.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$67.28
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,786.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$2,090.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$61.43
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$3,228.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$21.94
|
| Rate for Payer: United Healthcare Commercial |
$3,228.00
|
| Rate for Payer: United Healthcare Medicare |
$58.50
|
| Rate for Payer: WellCare Medicare |
$80.44
|
|
|
OCCULT BLOOD OTHER SOURCES
|
Facility
|
IP
|
$16.00
|
|
|
Service Code
|
HCPCS 82271
|
| Hospital Charge Code |
4301241
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$10.40 |
| Max. Negotiated Rate |
$10.40 |
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Galaxy Health Commercial |
$10.40
|
|
|
OCCULT BLOOD OTHER SOURCES
|
Facility
|
OP
|
$16.00
|
|
|
Service Code
|
HCPCS 82271
|
| Hospital Charge Code |
4301241
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$2.40 |
| Max. Negotiated Rate |
$12.80 |
| Rate for Payer: Aetna of NY Commercial |
$10.40
|
| Rate for Payer: Aetna of NY Medicare |
$7.36
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$6.40
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: CDPHP Medicare |
$5.92
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$9.60
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$12.80
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$12.80
|
| Rate for Payer: EmblemHealth Medicaid |
$12.80
|
| Rate for Payer: EmblemHealth Medicare |
$5.44
|
| Rate for Payer: EmblemHealth Select Care |
$9.60
|
| Rate for Payer: Fidelis Medicare |
$6.40
|
| Rate for Payer: Galaxy Health Commercial |
$10.40
|
| Rate for Payer: Hamaspik Choice Medicare |
$6.40
|
| Rate for Payer: Humana Medicare |
$6.40
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$10.40
|
| Rate for Payer: Local 1199SEIU Medicare |
$7.36
|
| Rate for Payer: MVP Health Care of NY Commercial |
$12.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$9.01
|
| Rate for Payer: MVP Health Care of NY Medicare |
$6.72
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$12.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$2.40
|
| Rate for Payer: United Healthcare Commercial |
$12.00
|
| Rate for Payer: United Healthcare Medicare |
$6.40
|
| Rate for Payer: WellCare Medicare |
$8.80
|
|
|
OCCULT BLOOD-STOOL
|
Facility
|
IP
|
$13.00
|
|
|
Service Code
|
HCPCS 82272
|
| Hospital Charge Code |
4300588
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$8.45 |
| Max. Negotiated Rate |
$8.45 |
| Rate for Payer: Cash Price |
$9.75
|
| Rate for Payer: Galaxy Health Commercial |
$8.45
|
|
|
OCCULT BLOOD-STOOL
|
Facility
|
OP
|
$13.00
|
|
|
Service Code
|
HCPCS 82272
|
| Hospital Charge Code |
4300588
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$1.95 |
| Max. Negotiated Rate |
$10.40 |
| Rate for Payer: Aetna of NY Commercial |
$8.45
|
| Rate for Payer: Aetna of NY Medicare |
$5.98
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$5.20
|
| Rate for Payer: Cash Price |
$9.75
|
| Rate for Payer: CDPHP Medicare |
$4.81
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$7.80
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$10.40
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$10.40
|
| Rate for Payer: EmblemHealth Medicaid |
$10.40
|
| Rate for Payer: EmblemHealth Medicare |
$4.42
|
| Rate for Payer: EmblemHealth Select Care |
$7.80
|
| Rate for Payer: Fidelis Medicare |
$5.20
|
| Rate for Payer: Galaxy Health Commercial |
$8.45
|
| Rate for Payer: Hamaspik Choice Medicare |
$5.20
|
| Rate for Payer: Humana Medicare |
$5.20
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$8.45
|
| Rate for Payer: Local 1199SEIU Medicare |
$5.98
|
| Rate for Payer: MVP Health Care of NY Commercial |
$9.75
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$7.32
|
| Rate for Payer: MVP Health Care of NY Medicare |
$5.46
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$9.75
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$1.95
|
| Rate for Payer: United Healthcare Commercial |
$9.75
|
| Rate for Payer: United Healthcare Medicare |
$5.20
|
| Rate for Payer: WellCare Medicare |
$7.15
|
|
|
OCTREOTIDE 1,000 MCG/5 ML VIAL 200 mcg, 5 mL
|
Facility
|
IP
|
$9.00
|
|
|
Service Code
|
HCPCS J2354
|
| Hospital Charge Code |
4401408
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$5.85 |
| Rate for Payer: Aetna of NY Commercial |
$4.95
|
| Rate for Payer: Cash Price |
$6.75
|
| Rate for Payer: Cash Price |
$6.75
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$0.62
|
| Rate for Payer: EmblemHealth Select Care |
$0.62
|
| Rate for Payer: Galaxy Health Commercial |
$5.85
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$4.95
|
| Rate for Payer: WellCare Medicare |
$4.95
|
|
|
OCTREOTIDE 1,000 MCG/5 ML VIAL 200 mcg, 5 mL
|
Facility
|
OP
|
$9.00
|
|
|
Service Code
|
HCPCS J2354
|
| Hospital Charge Code |
4401408
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$7.20 |
| Rate for Payer: Aetna of NY Medicare |
$4.14
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$3.60
|
| Rate for Payer: Cash Price |
$6.75
|
| Rate for Payer: Cash Price |
$6.75
|
| Rate for Payer: CDPHP Medicare |
$3.33
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$0.62
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$7.20
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$7.20
|
| Rate for Payer: EmblemHealth Medicaid |
$7.20
|
| Rate for Payer: EmblemHealth Medicare |
$3.06
|
| Rate for Payer: EmblemHealth Select Care |
$0.62
|
| Rate for Payer: Fidelis Medicare |
$3.60
|
| Rate for Payer: Galaxy Health Commercial |
$5.85
|
| Rate for Payer: Hamaspik Choice Medicare |
$3.60
|
| Rate for Payer: Humana Medicare |
$3.60
|
| Rate for Payer: Local 1199SEIU Medicare |
$4.14
|
| Rate for Payer: MVP Health Care of NY Commercial |
$6.75
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$5.07
|
| Rate for Payer: MVP Health Care of NY Medicare |
$3.78
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$2.16
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$1.35
|
| Rate for Payer: United Healthcare Commercial |
$2.16
|
| Rate for Payer: United Healthcare Medicare |
$3.60
|
| Rate for Payer: WellCare Medicare |
$4.95
|
|
|
OCTREOTIDE NOT DEPOT 25 MCG INJ
|
Facility
|
OP
|
$36.82
|
|
|
Service Code
|
HCPCS J2354
|
| Hospital Charge Code |
4400583
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$29.46 |
| Rate for Payer: Aetna of NY Medicare |
$16.94
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$14.73
|
| Rate for Payer: Cash Price |
$27.62
|
| Rate for Payer: Cash Price |
$27.62
|
| Rate for Payer: CDPHP Medicare |
$13.62
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$0.62
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$29.46
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$29.46
|
| Rate for Payer: EmblemHealth Medicaid |
$29.46
|
| Rate for Payer: EmblemHealth Medicare |
$12.52
|
| Rate for Payer: EmblemHealth Select Care |
$0.62
|
| Rate for Payer: Fidelis Medicare |
$14.73
|
| Rate for Payer: Galaxy Health Commercial |
$23.93
|
| Rate for Payer: Hamaspik Choice Medicare |
$14.73
|
| Rate for Payer: Humana Medicare |
$14.73
|
| Rate for Payer: Local 1199SEIU Medicare |
$16.94
|
| Rate for Payer: MVP Health Care of NY Commercial |
$27.61
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$20.73
|
| Rate for Payer: MVP Health Care of NY Medicare |
$15.46
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$2.16
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$5.52
|
| Rate for Payer: United Healthcare Commercial |
$2.16
|
| Rate for Payer: United Healthcare Medicare |
$14.73
|
| Rate for Payer: WellCare Medicare |
$20.25
|
|
|
OCTREOTIDE NOT DEPOT 25 MCG INJ
|
Facility
|
IP
|
$36.82
|
|
|
Service Code
|
HCPCS J2354
|
| Hospital Charge Code |
4400583
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$23.93 |
| Rate for Payer: Aetna of NY Commercial |
$20.25
|
| Rate for Payer: Cash Price |
$27.62
|
| Rate for Payer: Cash Price |
$27.62
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$0.62
|
| Rate for Payer: EmblemHealth Select Care |
$0.62
|
| Rate for Payer: Galaxy Health Commercial |
$23.93
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$20.25
|
| Rate for Payer: WellCare Medicare |
$20.25
|
|
|
OCTRODE PERM LEAD
|
Facility
|
OP
|
$10,551.32
|
|
| Hospital Charge Code |
4471276
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$1,582.70 |
| Max. Negotiated Rate |
$8,441.06 |
| Rate for Payer: Aetna of NY Commercial |
$7,385.92
|
| Rate for Payer: Aetna of NY Medicare |
$4,853.61
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$4,220.53
|
| Rate for Payer: Cash Price |
$7,913.49
|
| Rate for Payer: CDPHP Medicare |
$3,903.99
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$8,441.06
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$8,441.06
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$8,441.06
|
| Rate for Payer: EmblemHealth Medicaid |
$8,441.06
|
| Rate for Payer: EmblemHealth Medicare |
$3,587.45
|
| Rate for Payer: EmblemHealth Select Care |
$7,596.95
|
| Rate for Payer: Fidelis Medicare |
$4,220.53
|
| Rate for Payer: Galaxy Health Commercial |
$6,858.36
|
| Rate for Payer: Hamaspik Choice Medicare |
$4,220.53
|
| Rate for Payer: Humana Medicare |
$4,220.53
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$7,385.92
|
| Rate for Payer: Local 1199SEIU Medicare |
$4,853.61
|
| Rate for Payer: MVP Health Care of NY Commercial |
$7,913.49
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$5,940.39
|
| Rate for Payer: MVP Health Care of NY Medicare |
$4,431.55
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$1,582.70
|
| Rate for Payer: United Healthcare Medicare |
$4,220.53
|
| Rate for Payer: WellCare Medicare |
$5,803.23
|
|
|
OCTRODE PERM LEAD
|
Facility
|
IP
|
$10,551.32
|
|
| Hospital Charge Code |
4471276
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$6,858.36 |
| Max. Negotiated Rate |
$6,858.36 |
| Rate for Payer: Cash Price |
$7,913.49
|
| Rate for Payer: Galaxy Health Commercial |
$6,858.36
|
|
|
OFFICE/OUTPATIENT ESTABLISHED HIGH MDM 40 MIN
|
Facility
|
IP
|
$333.00
|
|
|
Service Code
|
HCPCS 99215
|
| Hospital Charge Code |
5160009
|
|
Hospital Revenue Code
|
516
|
| Min. Negotiated Rate |
$216.45 |
| Max. Negotiated Rate |
$216.45 |
| Rate for Payer: Cash Price |
$249.75
|
| Rate for Payer: Galaxy Health Commercial |
$216.45
|
|
