|
R SMALL WRIST W/ABDUCTED THUMB
|
Facility
|
IP
|
$57.00
|
|
| Hospital Charge Code |
4471575
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$37.05 |
| Max. Negotiated Rate |
$37.05 |
| Rate for Payer: Cash Price |
$42.75
|
| Rate for Payer: Galaxy Health Commercial |
$37.05
|
|
|
R SMALL WRIST W/ABDUCTED THUMB
|
Facility
|
OP
|
$57.00
|
|
| Hospital Charge Code |
4471575
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$19.38 |
| Max. Negotiated Rate |
$45.88 |
| Rate for Payer: Aetna of NY Commercial |
$39.90
|
| Rate for Payer: Aetna of NY Medicare |
$26.22
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$42.75
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$42.75
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$21.09
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$28.50
|
| Rate for Payer: Cash Price |
$42.75
|
| Rate for Payer: CDPHP Commercial |
$45.88
|
| Rate for Payer: CDPHP Medicare |
$21.09
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$45.60
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$45.60
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$45.60
|
| Rate for Payer: EmblemHealth Medicaid |
$45.60
|
| Rate for Payer: EmblemHealth Medicare |
$19.38
|
| Rate for Payer: EmblemHealth Select Care |
$41.04
|
| Rate for Payer: Fidelis Medicare |
$21.72
|
| Rate for Payer: Galaxy Health Commercial |
$37.05
|
| Rate for Payer: Hamaspik Choice Medicare |
$21.09
|
| Rate for Payer: Humana Medicare |
$21.09
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$39.90
|
| Rate for Payer: Local 1199SEIU Medicare |
$26.22
|
| Rate for Payer: MVP Health Care of NY Commercial |
$42.75
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$32.09
|
| Rate for Payer: MVP Health Care of NY Medicare |
$22.14
|
| Rate for Payer: United Healthcare Medicare |
$21.09
|
| Rate for Payer: WellCare Medicare |
$31.35
|
|
|
RSV IA W DIR OBSERV-CULTURE
|
Facility
|
IP
|
$100.00
|
|
|
Service Code
|
HCPCS 87807
|
| Hospital Charge Code |
4301171
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$65.00 |
| Max. Negotiated Rate |
$65.00 |
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Galaxy Health Commercial |
$65.00
|
|
|
RSV IA W DIR OBSERV-CULTURE
|
Facility
|
OP
|
$100.00
|
|
|
Service Code
|
HCPCS 87807
|
| Hospital Charge Code |
4301171
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.10 |
| Max. Negotiated Rate |
$80.50 |
| Rate for Payer: Aetna of NY Commercial |
$65.00
|
| Rate for Payer: Aetna of NY Medicare |
$46.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$75.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$75.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$37.00
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$50.00
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: CDPHP Commercial |
$80.50
|
| Rate for Payer: CDPHP Medicare |
$37.00
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$60.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$80.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$80.00
|
| Rate for Payer: EmblemHealth Medicaid |
$80.00
|
| Rate for Payer: EmblemHealth Medicare |
$34.00
|
| Rate for Payer: EmblemHealth Select Care |
$60.00
|
| Rate for Payer: Fidelis Medicare |
$38.11
|
| Rate for Payer: Galaxy Health Commercial |
$65.00
|
| Rate for Payer: Hamaspik Choice Medicare |
$37.00
|
| Rate for Payer: Humana Medicare |
$37.00
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$65.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$46.00
|
| Rate for Payer: MVP Health Care of NY Commercial |
$75.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$56.30
|
| Rate for Payer: MVP Health Care of NY Medicare |
$38.85
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$75.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$13.10
|
| Rate for Payer: United Healthcare Commercial |
$75.00
|
| Rate for Payer: United Healthcare Medicare |
$37.00
|
| Rate for Payer: WellCare Medicare |
$55.00
|
|
|
RUBELLA ABS IGM
|
Facility
|
IP
|
$134.00
|
|
|
Service Code
|
HCPCS 86762
|
| Hospital Charge Code |
4300710
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$87.10 |
| Max. Negotiated Rate |
$87.10 |
| Rate for Payer: Cash Price |
$100.50
|
| Rate for Payer: Galaxy Health Commercial |
$87.10
|
|
|
RUBELLA ABS IGM
|
Facility
|
OP
|
$134.00
|
|
|
Service Code
|
HCPCS 86762
|
| Hospital Charge Code |
4300710
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$14.39 |
| Max. Negotiated Rate |
$107.87 |
| Rate for Payer: Aetna of NY Commercial |
$87.10
|
| Rate for Payer: Aetna of NY Medicare |
$61.64
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$100.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$100.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$49.58
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$67.00
|
| Rate for Payer: Cash Price |
$100.50
|
| Rate for Payer: Cash Price |
$100.50
|
| Rate for Payer: CDPHP Commercial |
$107.87
|
| Rate for Payer: CDPHP Medicare |
$49.58
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$80.40
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$107.20
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$107.20
|
| Rate for Payer: EmblemHealth Medicaid |
$107.20
|
| Rate for Payer: EmblemHealth Medicare |
$45.56
|
| Rate for Payer: EmblemHealth Select Care |
$80.40
|
| Rate for Payer: Fidelis Medicare |
$51.07
|
| Rate for Payer: Galaxy Health Commercial |
$87.10
|
| Rate for Payer: Hamaspik Choice Medicare |
$49.58
|
| Rate for Payer: Humana Medicare |
$49.58
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$87.10
|
| Rate for Payer: Local 1199SEIU Medicare |
$61.64
|
| Rate for Payer: MVP Health Care of NY Commercial |
$100.50
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$75.44
|
| Rate for Payer: MVP Health Care of NY Medicare |
$52.06
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$100.50
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$14.39
|
| Rate for Payer: United Healthcare Commercial |
$100.50
|
| Rate for Payer: United Healthcare Medicare |
$49.58
|
| Rate for Payer: WellCare Medicare |
$73.70
|
|
|
RUSSELL VIPER VENOM TIME DILUTED
|
Facility
|
OP
|
$37.00
|
|
|
Service Code
|
HCPCS 85613
|
| Hospital Charge Code |
4302013
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$7.90 |
| Max. Negotiated Rate |
$29.78 |
| Rate for Payer: Aetna of NY Commercial |
$24.05
|
| Rate for Payer: Aetna of NY Medicare |
$17.02
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$27.75
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$27.75
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$13.69
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$18.50
|
| Rate for Payer: Cash Price |
$27.75
|
| Rate for Payer: Cash Price |
$27.75
|
| Rate for Payer: CDPHP Commercial |
$29.78
|
| Rate for Payer: CDPHP Medicare |
$13.69
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$22.20
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$29.60
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$29.60
|
| Rate for Payer: EmblemHealth Medicaid |
$29.60
|
| Rate for Payer: EmblemHealth Medicare |
$12.58
|
| Rate for Payer: EmblemHealth Select Care |
$22.20
|
| Rate for Payer: Fidelis Medicare |
$14.10
|
| Rate for Payer: Galaxy Health Commercial |
$24.05
|
| Rate for Payer: Hamaspik Choice Medicare |
$13.69
|
| Rate for Payer: Humana Medicare |
$13.69
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$24.05
|
| Rate for Payer: Local 1199SEIU Medicare |
$17.02
|
| Rate for Payer: MVP Health Care of NY Commercial |
$27.75
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$20.83
|
| Rate for Payer: MVP Health Care of NY Medicare |
$14.37
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$27.75
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$7.90
|
| Rate for Payer: United Healthcare Commercial |
$27.75
|
| Rate for Payer: United Healthcare Medicare |
$13.69
|
| Rate for Payer: WellCare Medicare |
$20.35
|
|
|
RUSSELL VIPER VENOM TIME DILUTED
|
Facility
|
IP
|
$37.00
|
|
|
Service Code
|
HCPCS 85613
|
| Hospital Charge Code |
4302013
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$24.05 |
| Max. Negotiated Rate |
$24.05 |
| Rate for Payer: Cash Price |
$27.75
|
| Rate for Payer: Galaxy Health Commercial |
$24.05
|
|
|
R XL WRIST W/ABDUCTED THUMB
|
Facility
|
IP
|
$57.00
|
|
| Hospital Charge Code |
4471578
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$37.05 |
| Max. Negotiated Rate |
$37.05 |
| Rate for Payer: Cash Price |
$42.75
|
| Rate for Payer: Galaxy Health Commercial |
$37.05
|
|
|
R XL WRIST W/ABDUCTED THUMB
|
Facility
|
OP
|
$57.00
|
|
| Hospital Charge Code |
4471578
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$19.38 |
| Max. Negotiated Rate |
$45.88 |
| Rate for Payer: Aetna of NY Commercial |
$39.90
|
| Rate for Payer: Aetna of NY Medicare |
$26.22
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$42.75
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$42.75
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$21.09
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$28.50
|
| Rate for Payer: Cash Price |
$42.75
|
| Rate for Payer: CDPHP Commercial |
$45.88
|
| Rate for Payer: CDPHP Medicare |
$21.09
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$45.60
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$45.60
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$45.60
|
| Rate for Payer: EmblemHealth Medicaid |
$45.60
|
| Rate for Payer: EmblemHealth Medicare |
$19.38
|
| Rate for Payer: EmblemHealth Select Care |
$41.04
|
| Rate for Payer: Fidelis Medicare |
$21.72
|
| Rate for Payer: Galaxy Health Commercial |
$37.05
|
| Rate for Payer: Hamaspik Choice Medicare |
$21.09
|
| Rate for Payer: Humana Medicare |
$21.09
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$39.90
|
| Rate for Payer: Local 1199SEIU Medicare |
$26.22
|
| Rate for Payer: MVP Health Care of NY Commercial |
$42.75
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$32.09
|
| Rate for Payer: MVP Health Care of NY Medicare |
$22.14
|
| Rate for Payer: United Healthcare Medicare |
$21.09
|
| Rate for Payer: WellCare Medicare |
$31.35
|
|
|
R XS WRIST W/ABDUCTED THUMB
|
Facility
|
IP
|
$58.00
|
|
| Hospital Charge Code |
4471574
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$37.70 |
| Max. Negotiated Rate |
$37.70 |
| Rate for Payer: Cash Price |
$43.50
|
| Rate for Payer: Galaxy Health Commercial |
$37.70
|
|
|
R XS WRIST W/ABDUCTED THUMB
|
Facility
|
OP
|
$58.00
|
|
| Hospital Charge Code |
4471574
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$19.72 |
| Max. Negotiated Rate |
$46.69 |
| Rate for Payer: Aetna of NY Commercial |
$40.60
|
| Rate for Payer: Aetna of NY Medicare |
$26.68
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$43.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$43.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$21.46
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$29.00
|
| Rate for Payer: Cash Price |
$43.50
|
| Rate for Payer: CDPHP Commercial |
$46.69
|
| Rate for Payer: CDPHP Medicare |
$21.46
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$46.40
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$46.40
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$46.40
|
| Rate for Payer: EmblemHealth Medicaid |
$46.40
|
| Rate for Payer: EmblemHealth Medicare |
$19.72
|
| Rate for Payer: EmblemHealth Select Care |
$41.76
|
| Rate for Payer: Fidelis Medicare |
$22.10
|
| Rate for Payer: Galaxy Health Commercial |
$37.70
|
| Rate for Payer: Hamaspik Choice Medicare |
$21.46
|
| Rate for Payer: Humana Medicare |
$21.46
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$40.60
|
| Rate for Payer: Local 1199SEIU Medicare |
$26.68
|
| Rate for Payer: MVP Health Care of NY Commercial |
$43.50
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$32.65
|
| Rate for Payer: MVP Health Care of NY Medicare |
$22.53
|
| Rate for Payer: United Healthcare Medicare |
$21.46
|
| Rate for Payer: WellCare Medicare |
$31.90
|
|
|
SALEM SUMP 10FR
|
Facility
|
OP
|
$1,559.00
|
|
| Hospital Charge Code |
4471333
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$530.06 |
| Max. Negotiated Rate |
$1,255.00 |
| Rate for Payer: Aetna of NY Commercial |
$1,091.30
|
| Rate for Payer: Aetna of NY Medicare |
$717.14
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$701.55
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$701.55
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$576.83
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$779.50
|
| Rate for Payer: Cash Price |
$1,169.25
|
| Rate for Payer: CDPHP Commercial |
$1,255.00
|
| Rate for Payer: CDPHP Medicare |
$576.83
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$779.50
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$1,247.20
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$1,247.20
|
| Rate for Payer: EmblemHealth Medicaid |
$1,247.20
|
| Rate for Payer: EmblemHealth Medicare |
$530.06
|
| Rate for Payer: EmblemHealth Select Care |
$779.50
|
| Rate for Payer: Fidelis Medicare |
$594.13
|
| Rate for Payer: Galaxy Health Commercial |
$1,013.35
|
| Rate for Payer: Hamaspik Choice Medicare |
$576.83
|
| Rate for Payer: Humana Medicare |
$576.83
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,091.30
|
| Rate for Payer: Local 1199SEIU Medicare |
$717.14
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,013.35
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$1,013.35
|
| Rate for Payer: MVP Health Care of NY Medicare |
$605.67
|
| Rate for Payer: United Healthcare Medicare |
$576.83
|
| Rate for Payer: WellCare Medicare |
$857.45
|
|
|
SALEM SUMP 10FR
|
Facility
|
IP
|
$1,559.00
|
|
| Hospital Charge Code |
4471333
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$701.55 |
| Max. Negotiated Rate |
$1,091.30 |
| Rate for Payer: Aetna of NY Commercial |
$1,091.30
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$701.55
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$701.55
|
| Rate for Payer: Cash Price |
$1,169.25
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$779.50
|
| Rate for Payer: EmblemHealth Select Care |
$779.50
|
| Rate for Payer: Galaxy Health Commercial |
$1,013.35
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,091.30
|
| Rate for Payer: Multiplan Commercial |
$701.55
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,013.35
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$1,013.35
|
| Rate for Payer: WellCare Medicare |
$857.45
|
|
|
SALEM SUMP 12FR
|
Facility
|
IP
|
$1,559.00
|
|
| Hospital Charge Code |
4471335
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$701.55 |
| Max. Negotiated Rate |
$1,091.30 |
| Rate for Payer: Aetna of NY Commercial |
$1,091.30
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$701.55
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$701.55
|
| Rate for Payer: Cash Price |
$1,169.25
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$779.50
|
| Rate for Payer: EmblemHealth Select Care |
$779.50
|
| Rate for Payer: Galaxy Health Commercial |
$1,013.35
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,091.30
|
| Rate for Payer: Multiplan Commercial |
$701.55
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,013.35
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$1,013.35
|
| Rate for Payer: WellCare Medicare |
$857.45
|
|
|
SALEM SUMP 12FR
|
Facility
|
OP
|
$1,559.00
|
|
| Hospital Charge Code |
4471335
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$530.06 |
| Max. Negotiated Rate |
$1,255.00 |
| Rate for Payer: Aetna of NY Commercial |
$1,091.30
|
| Rate for Payer: Aetna of NY Medicare |
$717.14
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$701.55
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$701.55
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$576.83
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$779.50
|
| Rate for Payer: Cash Price |
$1,169.25
|
| Rate for Payer: CDPHP Commercial |
$1,255.00
|
| Rate for Payer: CDPHP Medicare |
$576.83
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$779.50
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$1,247.20
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$1,247.20
|
| Rate for Payer: EmblemHealth Medicaid |
$1,247.20
|
| Rate for Payer: EmblemHealth Medicare |
$530.06
|
| Rate for Payer: EmblemHealth Select Care |
$779.50
|
| Rate for Payer: Fidelis Medicare |
$594.13
|
| Rate for Payer: Galaxy Health Commercial |
$1,013.35
|
| Rate for Payer: Hamaspik Choice Medicare |
$576.83
|
| Rate for Payer: Humana Medicare |
$576.83
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,091.30
|
| Rate for Payer: Local 1199SEIU Medicare |
$717.14
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,013.35
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$1,013.35
|
| Rate for Payer: MVP Health Care of NY Medicare |
$605.67
|
| Rate for Payer: United Healthcare Medicare |
$576.83
|
| Rate for Payer: WellCare Medicare |
$857.45
|
|
|
SALEM SUMP 14FR
|
Facility
|
OP
|
$6.00
|
|
| Hospital Charge Code |
4471338
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2.04 |
| Max. Negotiated Rate |
$4.83 |
| Rate for Payer: Aetna of NY Commercial |
$4.20
|
| Rate for Payer: Aetna of NY Medicare |
$2.76
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$2.70
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$2.70
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$2.22
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$3.00
|
| Rate for Payer: Cash Price |
$4.50
|
| Rate for Payer: CDPHP Commercial |
$4.83
|
| Rate for Payer: CDPHP Medicare |
$2.22
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$3.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$4.80
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$4.80
|
| Rate for Payer: EmblemHealth Medicaid |
$4.80
|
| Rate for Payer: EmblemHealth Medicare |
$2.04
|
| Rate for Payer: EmblemHealth Select Care |
$3.00
|
| Rate for Payer: Fidelis Medicare |
$2.29
|
| Rate for Payer: Galaxy Health Commercial |
$3.90
|
| Rate for Payer: Hamaspik Choice Medicare |
$2.22
|
| Rate for Payer: Humana Medicare |
$2.22
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$4.20
|
| Rate for Payer: Local 1199SEIU Medicare |
$2.76
|
| Rate for Payer: MVP Health Care of NY Commercial |
$3.90
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$3.90
|
| Rate for Payer: MVP Health Care of NY Medicare |
$2.33
|
| Rate for Payer: United Healthcare Medicare |
$2.22
|
| Rate for Payer: WellCare Medicare |
$3.30
|
|
|
SALEM SUMP 14FR
|
Facility
|
IP
|
$6.00
|
|
| Hospital Charge Code |
4471338
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2.70 |
| Max. Negotiated Rate |
$4.20 |
| Rate for Payer: Aetna of NY Commercial |
$4.20
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$2.70
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$2.70
|
| Rate for Payer: Cash Price |
$4.50
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$3.00
|
| Rate for Payer: EmblemHealth Select Care |
$3.00
|
| Rate for Payer: Galaxy Health Commercial |
$3.90
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$4.20
|
| Rate for Payer: Multiplan Commercial |
$2.70
|
| Rate for Payer: MVP Health Care of NY Commercial |
$3.90
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$3.90
|
| Rate for Payer: WellCare Medicare |
$3.30
|
|
|
SALEM SUMP 16FR
|
Facility
|
OP
|
$5.00
|
|
| Hospital Charge Code |
4471339
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1.70 |
| Max. Negotiated Rate |
$4.02 |
| Rate for Payer: Aetna of NY Commercial |
$3.50
|
| Rate for Payer: Aetna of NY Medicare |
$2.30
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$2.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$2.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$1.85
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$2.50
|
| Rate for Payer: Cash Price |
$3.75
|
| Rate for Payer: CDPHP Commercial |
$4.02
|
| Rate for Payer: CDPHP Medicare |
$1.85
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$2.50
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$4.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$4.00
|
| Rate for Payer: EmblemHealth Medicaid |
$4.00
|
| Rate for Payer: EmblemHealth Medicare |
$1.70
|
| Rate for Payer: EmblemHealth Select Care |
$2.50
|
| Rate for Payer: Fidelis Medicare |
$1.91
|
| Rate for Payer: Galaxy Health Commercial |
$3.25
|
| Rate for Payer: Hamaspik Choice Medicare |
$1.85
|
| Rate for Payer: Humana Medicare |
$1.85
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$3.50
|
| Rate for Payer: Local 1199SEIU Medicare |
$2.30
|
| Rate for Payer: MVP Health Care of NY Commercial |
$3.25
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$3.25
|
| Rate for Payer: MVP Health Care of NY Medicare |
$1.94
|
| Rate for Payer: United Healthcare Medicare |
$1.85
|
| Rate for Payer: WellCare Medicare |
$2.75
|
|
|
SALEM SUMP 16FR
|
Facility
|
IP
|
$5.00
|
|
| Hospital Charge Code |
4471339
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2.25 |
| Max. Negotiated Rate |
$3.50 |
| Rate for Payer: Aetna of NY Commercial |
$3.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$2.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$2.25
|
| Rate for Payer: Cash Price |
$3.75
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$2.50
|
| Rate for Payer: EmblemHealth Select Care |
$2.50
|
| Rate for Payer: Galaxy Health Commercial |
$3.25
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$3.50
|
| Rate for Payer: Multiplan Commercial |
$2.25
|
| Rate for Payer: MVP Health Care of NY Commercial |
$3.25
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$3.25
|
| Rate for Payer: WellCare Medicare |
$2.75
|
|
|
SALEM SUMP 18FR
|
Facility
|
IP
|
$6.00
|
|
| Hospital Charge Code |
4471340
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2.70 |
| Max. Negotiated Rate |
$4.20 |
| Rate for Payer: Aetna of NY Commercial |
$4.20
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$2.70
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$2.70
|
| Rate for Payer: Cash Price |
$4.50
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$3.00
|
| Rate for Payer: EmblemHealth Select Care |
$3.00
|
| Rate for Payer: Galaxy Health Commercial |
$3.90
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$4.20
|
| Rate for Payer: Multiplan Commercial |
$2.70
|
| Rate for Payer: MVP Health Care of NY Commercial |
$3.90
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$3.90
|
| Rate for Payer: WellCare Medicare |
$3.30
|
|
|
SALEM SUMP 18FR
|
Facility
|
OP
|
$6.00
|
|
| Hospital Charge Code |
4471340
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2.04 |
| Max. Negotiated Rate |
$4.83 |
| Rate for Payer: Aetna of NY Commercial |
$4.20
|
| Rate for Payer: Aetna of NY Medicare |
$2.76
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$2.70
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$2.70
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$2.22
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$3.00
|
| Rate for Payer: Cash Price |
$4.50
|
| Rate for Payer: CDPHP Commercial |
$4.83
|
| Rate for Payer: CDPHP Medicare |
$2.22
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$3.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$4.80
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$4.80
|
| Rate for Payer: EmblemHealth Medicaid |
$4.80
|
| Rate for Payer: EmblemHealth Medicare |
$2.04
|
| Rate for Payer: EmblemHealth Select Care |
$3.00
|
| Rate for Payer: Fidelis Medicare |
$2.29
|
| Rate for Payer: Galaxy Health Commercial |
$3.90
|
| Rate for Payer: Hamaspik Choice Medicare |
$2.22
|
| Rate for Payer: Humana Medicare |
$2.22
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$4.20
|
| Rate for Payer: Local 1199SEIU Medicare |
$2.76
|
| Rate for Payer: MVP Health Care of NY Commercial |
$3.90
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$3.90
|
| Rate for Payer: MVP Health Care of NY Medicare |
$2.33
|
| Rate for Payer: United Healthcare Medicare |
$2.22
|
| Rate for Payer: WellCare Medicare |
$3.30
|
|
|
SALICYLATE
|
Facility
|
IP
|
$360.00
|
|
|
Service Code
|
HCPCS G0480
|
| Hospital Charge Code |
4300716
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$234.00 |
| Max. Negotiated Rate |
$234.00 |
| Rate for Payer: Cash Price |
$270.00
|
| Rate for Payer: Galaxy Health Commercial |
$234.00
|
|
|
SALICYLATE
|
Facility
|
OP
|
$360.00
|
|
|
Service Code
|
HCPCS G0480
|
| Hospital Charge Code |
4300716
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$15.15 |
| Max. Negotiated Rate |
$289.80 |
| Rate for Payer: Aetna of NY Commercial |
$234.00
|
| Rate for Payer: Aetna of NY Medicare |
$165.60
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$270.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$270.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$133.20
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$180.00
|
| Rate for Payer: Cash Price |
$270.00
|
| Rate for Payer: Cash Price |
$270.00
|
| Rate for Payer: CDPHP Commercial |
$289.80
|
| Rate for Payer: CDPHP Medicare |
$133.20
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$216.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$288.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$288.00
|
| Rate for Payer: EmblemHealth Medicaid |
$288.00
|
| Rate for Payer: EmblemHealth Medicare |
$122.40
|
| Rate for Payer: EmblemHealth Select Care |
$216.00
|
| Rate for Payer: Fidelis Medicare |
$137.20
|
| Rate for Payer: Galaxy Health Commercial |
$234.00
|
| Rate for Payer: Hamaspik Choice Medicare |
$133.20
|
| Rate for Payer: Humana Medicare |
$133.20
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$234.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$165.60
|
| Rate for Payer: MVP Health Care of NY Commercial |
$270.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$202.68
|
| Rate for Payer: MVP Health Care of NY Medicare |
$139.86
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$270.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$15.15
|
| Rate for Payer: United Healthcare Commercial |
$270.00
|
| Rate for Payer: United Healthcare Medicare |
$133.20
|
| Rate for Payer: WellCare Medicare |
$198.00
|
|
|
SARS-COV-2 COVID-19 ANTIBODY
|
Facility
|
OP
|
$162.00
|
|
|
Service Code
|
HCPCS 86769
|
| Hospital Charge Code |
4300005
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$25.28 |
| Max. Negotiated Rate |
$130.41 |
| Rate for Payer: Aetna of NY Commercial |
$105.30
|
| Rate for Payer: Aetna of NY Medicare |
$74.52
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$121.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$121.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$59.94
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$81.00
|
| Rate for Payer: Cash Price |
$121.50
|
| Rate for Payer: Cash Price |
$121.50
|
| Rate for Payer: CDPHP Commercial |
$130.41
|
| Rate for Payer: CDPHP Medicare |
$59.94
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$97.20
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$129.60
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$129.60
|
| Rate for Payer: EmblemHealth Medicaid |
$129.60
|
| Rate for Payer: EmblemHealth Medicare |
$55.08
|
| Rate for Payer: EmblemHealth Select Care |
$97.20
|
| Rate for Payer: Fidelis Medicare |
$61.74
|
| Rate for Payer: Galaxy Health Commercial |
$105.30
|
| Rate for Payer: Hamaspik Choice Medicare |
$59.94
|
| Rate for Payer: Humana Medicare |
$59.94
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$105.30
|
| Rate for Payer: Local 1199SEIU Medicare |
$74.52
|
| Rate for Payer: MVP Health Care of NY Commercial |
$121.50
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$91.21
|
| Rate for Payer: MVP Health Care of NY Medicare |
$62.94
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$121.50
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$25.28
|
| Rate for Payer: United Healthcare Commercial |
$121.50
|
| Rate for Payer: United Healthcare Medicare |
$59.94
|
| Rate for Payer: WellCare Medicare |
$89.10
|
|
