|
PEDIA LAX 4 OZ LIQ
|
Facility
|
IP
|
$6.18
|
|
|
Service Code
|
NDC 00132010624
|
| Hospital Charge Code |
4408980
|
|
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
|
|
|
PEDIA LAX 4 OZ LIQ
|
Facility
|
OP
|
$6.18
|
|
|
Service Code
|
NDC 00132010624
|
| Hospital Charge Code |
4408980
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.10 |
| Max. Negotiated Rate |
$4.97 |
| 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) Blue Access/Small Group |
$4.64
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$4.64
|
| 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: 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 |
$4.33
|
| 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: United Healthcare Medicare |
$2.29
|
| Rate for Payer: WellCare Medicare |
$3.40
|
|
|
PEDIATRIC CAPNOLINE (CANNULA)
|
Facility
|
OP
|
$42.00
|
|
| Hospital Charge Code |
4479200
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$14.28 |
| Max. Negotiated Rate |
$33.81 |
| Rate for Payer: Aetna of NY Commercial |
$29.40
|
| Rate for Payer: Aetna of NY Medicare |
$19.32
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$31.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$31.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$15.54
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$21.00
|
| Rate for Payer: Cash Price |
$31.50
|
| Rate for Payer: CDPHP Commercial |
$33.81
|
| Rate for Payer: CDPHP Medicare |
$15.54
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$33.60
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$33.60
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$33.60
|
| Rate for Payer: EmblemHealth Medicaid |
$33.60
|
| Rate for Payer: EmblemHealth Medicare |
$14.28
|
| Rate for Payer: EmblemHealth Select Care |
$30.24
|
| Rate for Payer: Fidelis Medicare |
$16.01
|
| Rate for Payer: Galaxy Health Commercial |
$27.30
|
| Rate for Payer: Hamaspik Choice Medicare |
$15.54
|
| Rate for Payer: Humana Medicare |
$15.54
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$29.40
|
| Rate for Payer: Local 1199SEIU Medicare |
$19.32
|
| Rate for Payer: MVP Health Care of NY Commercial |
$31.50
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$23.65
|
| Rate for Payer: MVP Health Care of NY Medicare |
$16.32
|
| Rate for Payer: United Healthcare Medicare |
$15.54
|
| Rate for Payer: WellCare Medicare |
$23.10
|
|
|
PEDIATRIC CAPNOLINE (CANNULA)
|
Facility
|
IP
|
$42.00
|
|
| Hospital Charge Code |
4479200
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$27.30 |
| Max. Negotiated Rate |
$27.30 |
| Rate for Payer: Cash Price |
$31.50
|
| Rate for Payer: Galaxy Health Commercial |
$27.30
|
|
|
PEDIATRIC DRAPE
|
Facility
|
IP
|
$24.00
|
|
| Hospital Charge Code |
4479161
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$15.60 |
| Max. Negotiated Rate |
$15.60 |
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Galaxy Health Commercial |
$15.60
|
|
|
PEDIATRIC DRAPE
|
Facility
|
OP
|
$24.00
|
|
| Hospital Charge Code |
4479161
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$8.16 |
| Max. Negotiated Rate |
$19.32 |
| Rate for Payer: Aetna of NY Commercial |
$16.80
|
| Rate for Payer: Aetna of NY Medicare |
$11.04
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$18.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$18.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$8.88
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$12.00
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: CDPHP Commercial |
$19.32
|
| Rate for Payer: CDPHP Medicare |
$8.88
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$19.20
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$19.20
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$19.20
|
| Rate for Payer: EmblemHealth Medicaid |
$19.20
|
| Rate for Payer: EmblemHealth Medicare |
$8.16
|
| Rate for Payer: EmblemHealth Select Care |
$17.28
|
| Rate for Payer: Fidelis Medicare |
$9.15
|
| Rate for Payer: Galaxy Health Commercial |
$15.60
|
| Rate for Payer: Hamaspik Choice Medicare |
$8.88
|
| Rate for Payer: Humana Medicare |
$8.88
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$16.80
|
| Rate for Payer: Local 1199SEIU Medicare |
$11.04
|
| Rate for Payer: MVP Health Care of NY Commercial |
$18.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$13.51
|
| Rate for Payer: MVP Health Care of NY Medicare |
$9.32
|
| Rate for Payer: United Healthcare Medicare |
$8.88
|
| Rate for Payer: WellCare Medicare |
$13.20
|
|
|
PEDIATRIC ELECTROLYTE SOLN ORAL
|
Facility
|
OP
|
$13.13
|
|
|
Service Code
|
NDC 37205022208
|
| Hospital Charge Code |
4408977
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.46 |
| Max. Negotiated Rate |
$10.57 |
| Rate for Payer: Aetna of NY Commercial |
$9.19
|
| Rate for Payer: Aetna of NY Medicare |
$6.04
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$9.85
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$9.85
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$4.86
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$6.56
|
| Rate for Payer: Cash Price |
$9.85
|
| Rate for Payer: CDPHP Commercial |
$10.57
|
| Rate for Payer: CDPHP Medicare |
$4.86
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$10.50
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$10.50
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$10.50
|
| Rate for Payer: EmblemHealth Medicaid |
$10.50
|
| Rate for Payer: EmblemHealth Medicare |
$4.46
|
| Rate for Payer: EmblemHealth Select Care |
$9.45
|
| Rate for Payer: Fidelis Medicare |
$5.00
|
| Rate for Payer: Galaxy Health Commercial |
$8.53
|
| Rate for Payer: Hamaspik Choice Medicare |
$4.86
|
| Rate for Payer: Humana Medicare |
$4.86
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$9.19
|
| Rate for Payer: Local 1199SEIU Medicare |
$6.04
|
| Rate for Payer: MVP Health Care of NY Commercial |
$9.85
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$7.39
|
| Rate for Payer: MVP Health Care of NY Medicare |
$5.10
|
| Rate for Payer: United Healthcare Medicare |
$4.86
|
| Rate for Payer: WellCare Medicare |
$7.22
|
|
|
PEDIATRIC ELECTROLYTE SOLN ORAL
|
Facility
|
IP
|
$13.13
|
|
|
Service Code
|
NDC 37205022208
|
| Hospital Charge Code |
4408977
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.22 |
| Max. Negotiated Rate |
$8.53 |
| Rate for Payer: Cash Price |
$9.85
|
| Rate for Payer: Galaxy Health Commercial |
$8.53
|
| Rate for Payer: WellCare Medicare |
$7.22
|
|
|
PEDIATRIC PACER PAD
|
Facility
|
OP
|
$64.00
|
|
| Hospital Charge Code |
4479116
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$21.76 |
| Max. Negotiated Rate |
$51.52 |
| Rate for Payer: Aetna of NY Commercial |
$44.80
|
| Rate for Payer: Aetna of NY Medicare |
$29.44
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$48.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$48.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$23.68
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$32.00
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: CDPHP Commercial |
$51.52
|
| Rate for Payer: CDPHP Medicare |
$23.68
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$51.20
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$51.20
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$51.20
|
| Rate for Payer: EmblemHealth Medicaid |
$51.20
|
| Rate for Payer: EmblemHealth Medicare |
$21.76
|
| Rate for Payer: EmblemHealth Select Care |
$46.08
|
| Rate for Payer: Fidelis Medicare |
$24.39
|
| Rate for Payer: Galaxy Health Commercial |
$41.60
|
| Rate for Payer: Hamaspik Choice Medicare |
$23.68
|
| Rate for Payer: Humana Medicare |
$23.68
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$44.80
|
| Rate for Payer: Local 1199SEIU Medicare |
$29.44
|
| Rate for Payer: MVP Health Care of NY Commercial |
$48.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$36.03
|
| Rate for Payer: MVP Health Care of NY Medicare |
$24.86
|
| Rate for Payer: United Healthcare Medicare |
$23.68
|
| Rate for Payer: WellCare Medicare |
$35.20
|
|
|
PEDIATRIC PACER PAD
|
Facility
|
IP
|
$64.00
|
|
| Hospital Charge Code |
4479116
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$41.60 |
| Max. Negotiated Rate |
$41.60 |
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Galaxy Health Commercial |
$41.60
|
|
|
PEDIATRIC PULSE OX
|
Facility
|
IP
|
$71.00
|
|
| Hospital Charge Code |
4479199
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$46.15 |
| Max. Negotiated Rate |
$46.15 |
| Rate for Payer: Cash Price |
$53.25
|
| Rate for Payer: Galaxy Health Commercial |
$46.15
|
|
|
PEDIATRIC PULSE OX
|
Facility
|
OP
|
$71.00
|
|
| Hospital Charge Code |
4479199
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$24.14 |
| Max. Negotiated Rate |
$57.16 |
| Rate for Payer: Aetna of NY Commercial |
$49.70
|
| Rate for Payer: Aetna of NY Medicare |
$32.66
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$53.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$53.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$26.27
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$35.50
|
| Rate for Payer: Cash Price |
$53.25
|
| Rate for Payer: CDPHP Commercial |
$57.16
|
| Rate for Payer: CDPHP Medicare |
$26.27
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$56.80
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$56.80
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$56.80
|
| Rate for Payer: EmblemHealth Medicaid |
$56.80
|
| Rate for Payer: EmblemHealth Medicare |
$24.14
|
| Rate for Payer: EmblemHealth Select Care |
$51.12
|
| Rate for Payer: Fidelis Medicare |
$27.06
|
| Rate for Payer: Galaxy Health Commercial |
$46.15
|
| Rate for Payer: Hamaspik Choice Medicare |
$26.27
|
| Rate for Payer: Humana Medicare |
$26.27
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$49.70
|
| Rate for Payer: Local 1199SEIU Medicare |
$32.66
|
| Rate for Payer: MVP Health Care of NY Commercial |
$53.25
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$39.97
|
| Rate for Payer: MVP Health Care of NY Medicare |
$27.58
|
| Rate for Payer: United Healthcare Medicare |
$26.27
|
| Rate for Payer: WellCare Medicare |
$39.05
|
|
|
PELVIS MRA W CONTR
|
Facility
|
OP
|
$2,847.00
|
|
|
Service Code
|
HCPCS C8918
|
| Hospital Charge Code |
4230070
|
|
Hospital Revenue Code
|
618
|
| Min. Negotiated Rate |
$366.42 |
| Max. Negotiated Rate |
$2,291.84 |
| Rate for Payer: Aetna of NY Commercial |
$1,738.00
|
| Rate for Payer: Aetna of NY Medicare |
$1,309.62
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$2,135.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$2,135.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$1,053.39
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$794.00
|
| Rate for Payer: Cash Price |
$2,135.25
|
| Rate for Payer: Cash Price |
$2,135.25
|
| Rate for Payer: Cash Price |
$2,135.25
|
| Rate for Payer: CDPHP Commercial |
$2,291.84
|
| Rate for Payer: CDPHP Medicare |
$1,053.39
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$1,992.90
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$2,277.60
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$2,277.60
|
| Rate for Payer: EmblemHealth Medicaid |
$2,277.60
|
| Rate for Payer: EmblemHealth Medicare |
$967.98
|
| Rate for Payer: EmblemHealth Select Care |
$1,850.55
|
| Rate for Payer: Fidelis Medicare |
$1,084.99
|
| Rate for Payer: Galaxy Health Commercial |
$1,850.55
|
| Rate for Payer: Hamaspik Choice Medicare |
$1,053.39
|
| Rate for Payer: Humana Medicare |
$1,053.39
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,738.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$1,309.62
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,270.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$918.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$1,106.06
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$2,260.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$366.42
|
| Rate for Payer: United Healthcare Commercial |
$2,260.00
|
| Rate for Payer: United Healthcare Medicare |
$1,053.39
|
| Rate for Payer: WellCare Medicare |
$1,565.85
|
|
|
PELVIS MRA W CONTR
|
Facility
|
IP
|
$2,847.00
|
|
|
Service Code
|
HCPCS C8918
|
| Hospital Charge Code |
4230070
|
|
Hospital Revenue Code
|
618
|
| Min. Negotiated Rate |
$1,850.55 |
| Max. Negotiated Rate |
$1,850.55 |
| Rate for Payer: Cash Price |
$2,135.25
|
| Rate for Payer: Galaxy Health Commercial |
$1,850.55
|
|
|
PELVIS MRA WO CONTR
|
Facility
|
IP
|
$1,915.00
|
|
|
Service Code
|
HCPCS C8919
|
| Hospital Charge Code |
4230120
|
|
Hospital Revenue Code
|
619
|
| Min. Negotiated Rate |
$1,244.75 |
| Max. Negotiated Rate |
$1,244.75 |
| Rate for Payer: Cash Price |
$1,436.25
|
| Rate for Payer: Galaxy Health Commercial |
$1,244.75
|
|
|
PELVIS MRA WO CONTR
|
Facility
|
OP
|
$1,915.00
|
|
|
Service Code
|
HCPCS C8919
|
| Hospital Charge Code |
4230120
|
|
Hospital Revenue Code
|
619
|
| Min. Negotiated Rate |
$233.47 |
| Max. Negotiated Rate |
$2,260.00 |
| Rate for Payer: Aetna of NY Commercial |
$1,738.00
|
| Rate for Payer: Aetna of NY Medicare |
$880.90
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$1,436.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$1,436.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$708.55
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$794.00
|
| Rate for Payer: Cash Price |
$1,436.25
|
| Rate for Payer: Cash Price |
$1,436.25
|
| Rate for Payer: Cash Price |
$1,436.25
|
| Rate for Payer: CDPHP Commercial |
$1,541.58
|
| Rate for Payer: CDPHP Medicare |
$708.55
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$1,340.50
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$1,532.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$1,532.00
|
| Rate for Payer: EmblemHealth Medicaid |
$1,532.00
|
| Rate for Payer: EmblemHealth Medicare |
$651.10
|
| Rate for Payer: EmblemHealth Select Care |
$1,244.75
|
| Rate for Payer: Fidelis Medicare |
$729.81
|
| Rate for Payer: Galaxy Health Commercial |
$1,244.75
|
| Rate for Payer: Hamaspik Choice Medicare |
$708.55
|
| Rate for Payer: Humana Medicare |
$708.55
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,738.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$880.90
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,270.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$918.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$743.98
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$2,260.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$233.47
|
| Rate for Payer: United Healthcare Commercial |
$2,260.00
|
| Rate for Payer: United Healthcare Medicare |
$708.55
|
| Rate for Payer: WellCare Medicare |
$1,053.25
|
|
|
PELVIS MRA W & WO CONTR
|
Facility
|
IP
|
$2,847.00
|
|
|
Service Code
|
HCPCS C8920
|
| Hospital Charge Code |
4230071
|
|
Hospital Revenue Code
|
618
|
| Min. Negotiated Rate |
$1,850.55 |
| Max. Negotiated Rate |
$1,850.55 |
| Rate for Payer: Cash Price |
$2,135.25
|
| Rate for Payer: Galaxy Health Commercial |
$1,850.55
|
|
|
PELVIS MRA W & WO CONTR
|
Facility
|
OP
|
$2,847.00
|
|
|
Service Code
|
HCPCS C8920
|
| Hospital Charge Code |
4230071
|
|
Hospital Revenue Code
|
618
|
| Min. Negotiated Rate |
$366.42 |
| Max. Negotiated Rate |
$2,291.84 |
| Rate for Payer: Aetna of NY Commercial |
$1,738.00
|
| Rate for Payer: Aetna of NY Medicare |
$1,309.62
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$2,135.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$2,135.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$1,053.39
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$794.00
|
| Rate for Payer: Cash Price |
$2,135.25
|
| Rate for Payer: Cash Price |
$2,135.25
|
| Rate for Payer: Cash Price |
$2,135.25
|
| Rate for Payer: CDPHP Commercial |
$2,291.84
|
| Rate for Payer: CDPHP Medicare |
$1,053.39
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$1,992.90
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$2,277.60
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$2,277.60
|
| Rate for Payer: EmblemHealth Medicaid |
$2,277.60
|
| Rate for Payer: EmblemHealth Medicare |
$967.98
|
| Rate for Payer: EmblemHealth Select Care |
$1,850.55
|
| Rate for Payer: Fidelis Medicare |
$1,084.99
|
| Rate for Payer: Galaxy Health Commercial |
$1,850.55
|
| Rate for Payer: Hamaspik Choice Medicare |
$1,053.39
|
| Rate for Payer: Humana Medicare |
$1,053.39
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,738.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$1,309.62
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,270.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$918.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$1,106.06
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$2,260.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$366.42
|
| Rate for Payer: United Healthcare Commercial |
$2,260.00
|
| Rate for Payer: United Healthcare Medicare |
$1,053.39
|
| Rate for Payer: WellCare Medicare |
$1,565.85
|
|
|
PENICILLIN V POTASSIUM 250MG/5ML POSR 10
|
Facility
|
IP
|
$6.18
|
|
|
Service Code
|
NDC 00093412773
|
| Hospital Charge Code |
4400615
|
|
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
|
|
|
PENICILLIN V POTASSIUM 250MG/5ML POSR 10
|
Facility
|
OP
|
$6.18
|
|
|
Service Code
|
NDC 00093412773
|
| Hospital Charge Code |
4400615
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.10 |
| Max. Negotiated Rate |
$4.97 |
| 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) Blue Access/Small Group |
$4.64
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$4.64
|
| 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: 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 |
$4.33
|
| 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: United Healthcare Medicare |
$2.29
|
| Rate for Payer: WellCare Medicare |
$3.40
|
|
|
PENICILLIN V POTASSIUM 500MG TABS 100 EA
|
Facility
|
IP
|
$6.18
|
|
|
Service Code
|
NDC 00781165501
|
| Hospital Charge Code |
4400616
|
|
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
|
|
|
PENICILLIN V POTASSIUM 500MG TABS 100 EA
|
Facility
|
OP
|
$6.18
|
|
|
Service Code
|
NDC 00781165501
|
| Hospital Charge Code |
4400616
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.10 |
| Max. Negotiated Rate |
$4.97 |
| 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) Blue Access/Small Group |
$4.64
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$4.64
|
| 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: 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 |
$4.33
|
| 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: United Healthcare Medicare |
$2.29
|
| Rate for Payer: WellCare Medicare |
$3.40
|
|
|
PERCUTANEOUS DECOMPRESSION DEVICE KIT #M
|
Facility
|
OP
|
$8,139.00
|
|
| Hospital Charge Code |
4478231
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$2,767.26 |
| Max. Negotiated Rate |
$6,551.90 |
| Rate for Payer: Aetna of NY Commercial |
$5,697.30
|
| Rate for Payer: Aetna of NY Medicare |
$3,743.94
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$6,104.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$6,104.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$3,011.43
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$4,069.50
|
| Rate for Payer: Cash Price |
$6,104.25
|
| Rate for Payer: CDPHP Commercial |
$6,551.90
|
| Rate for Payer: CDPHP Medicare |
$3,011.43
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$6,511.20
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$6,511.20
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$6,511.20
|
| Rate for Payer: EmblemHealth Medicaid |
$6,511.20
|
| Rate for Payer: EmblemHealth Medicare |
$2,767.26
|
| Rate for Payer: EmblemHealth Select Care |
$5,860.08
|
| Rate for Payer: Fidelis Medicare |
$3,101.77
|
| Rate for Payer: Galaxy Health Commercial |
$5,290.35
|
| Rate for Payer: Hamaspik Choice Medicare |
$3,011.43
|
| Rate for Payer: Humana Medicare |
$3,011.43
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$5,697.30
|
| Rate for Payer: Local 1199SEIU Medicare |
$3,743.94
|
| Rate for Payer: MVP Health Care of NY Commercial |
$6,104.25
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$4,582.26
|
| Rate for Payer: MVP Health Care of NY Medicare |
$3,162.00
|
| Rate for Payer: United Healthcare Medicare |
$3,011.43
|
| Rate for Payer: WellCare Medicare |
$4,476.45
|
|
|
PERCUTANEOUS DECOMPRESSION DEVICE KIT #M
|
Facility
|
IP
|
$8,139.00
|
|
| Hospital Charge Code |
4478231
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$5,290.35 |
| Max. Negotiated Rate |
$5,290.35 |
| Rate for Payer: Cash Price |
$6,104.25
|
| Rate for Payer: Galaxy Health Commercial |
$5,290.35
|
|
|
PERCUTANEOUS IMPLANTATION OF NEUROSTIMULATOR ELECTRODE ARRAY, EPIDURAL
|
Facility
|
OP
|
$314,327.00
|
|
|
Service Code
|
CPT 63650
|
|
Hospital Revenue Code
|
490
|
| Min. Negotiated Rate |
$1,421.00 |
| Max. Negotiated Rate |
$314,327.00 |
| 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 |
$2,973.46
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$3,716.31
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Essential Plan |
$7,072.36
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicaid |
$3,143.27
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$1,421.00
|
| Rate for Payer: CDPHP Child Health Plus/HARP/Select Plan |
$3,143.27
|
| Rate for Payer: CDPHP Essential Plan |
$7,072.36
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$3,771.92
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$3,143.27
|
| Rate for Payer: EmblemHealth Medicaid |
$3,143.27
|
| Rate for Payer: Fidelis Child Health Plus/Essential Plan/HARP/Medicaid |
$7,072.36
|
| Rate for Payer: Galaxy Health Workers Comp |
$4,620.61
|
| Rate for Payer: Hamaspik Choice Medicaid |
$314,327.00
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,857.00
|
| Rate for Payer: MVP Health Care of NY Child Health Plus/Family Health Plus/HARP/Medicaid |
$314,327.00
|
| Rate for Payer: MVP Health Care of NY Essential Plan 1&2 |
$6,758.03
|
| Rate for Payer: MVP Health Care of NY Essential Plan 3&4 |
$6,758.03
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$1,775.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$3,143.27
|
| Rate for Payer: United Healthcare Commercial |
$2,304.00
|
| Rate for Payer: WellCare Child Health Plus/Family Health Plus/Medicaid |
$3,300.43
|
|
