|
PHENYTOIN SOD EXTENDED 100MG CAPS 10X10E
|
Facility
|
IP
|
$6.18
|
|
|
Service Code
|
NDC 71036940
|
| Hospital Charge Code |
4400230
|
|
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
|
|
|
PHENYTOIN SOD EXTENDED 100MG CAPS 10X10E
|
Facility
|
OP
|
$6.18
|
|
|
Service Code
|
NDC 71036940
|
| Hospital Charge Code |
4400230
|
|
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
|
|
|
PHENYTOIN SODIUM, PER 50 MG
|
Facility
|
OP
|
$6.18
|
|
|
Service Code
|
HCPCS J1165
|
| Hospital Charge Code |
4400620
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.42 |
| Max. Negotiated Rate |
$4.94 |
| 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: Cash Price |
$4.64
|
| Rate for Payer: CDPHP Medicare |
$2.29
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$0.42
|
| 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 |
$0.42
|
| 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 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: Oxford Health Plans Freedom/Liberty/Metro |
$1.04
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$0.93
|
| Rate for Payer: United Healthcare Commercial |
$1.04
|
| Rate for Payer: United Healthcare Medicare |
$2.47
|
| Rate for Payer: WellCare Medicare |
$3.40
|
|
|
PHENYTOIN SODIUM, PER 50 MG
|
Facility
|
IP
|
$6.18
|
|
|
Service Code
|
HCPCS J1165
|
| Hospital Charge Code |
4400620
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.42 |
| Max. Negotiated Rate |
$4.02 |
| Rate for Payer: Aetna of NY Commercial |
$3.40
|
| Rate for Payer: Cash Price |
$4.64
|
| Rate for Payer: Cash Price |
$4.64
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$0.42
|
| Rate for Payer: EmblemHealth Select Care |
$0.42
|
| Rate for Payer: Galaxy Health Commercial |
$4.02
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$3.40
|
| Rate for Payer: WellCare Medicare |
$3.40
|
|
|
PHILLIPS MASK AF531
|
Facility
|
IP
|
$161.71
|
|
| Hospital Charge Code |
4473005
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$105.11 |
| Max. Negotiated Rate |
$105.11 |
| Rate for Payer: Cash Price |
$121.28
|
| Rate for Payer: Galaxy Health Commercial |
$105.11
|
|
|
PHILLIPS MASK AF531
|
Facility
|
OP
|
$161.71
|
|
| Hospital Charge Code |
4473005
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$24.26 |
| Max. Negotiated Rate |
$129.37 |
| Rate for Payer: Aetna of NY Commercial |
$113.20
|
| Rate for Payer: Aetna of NY Medicare |
$74.39
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$64.68
|
| Rate for Payer: Cash Price |
$121.28
|
| Rate for Payer: CDPHP Medicare |
$59.83
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$129.37
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$129.37
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$129.37
|
| Rate for Payer: EmblemHealth Medicaid |
$129.37
|
| Rate for Payer: EmblemHealth Medicare |
$54.98
|
| Rate for Payer: EmblemHealth Select Care |
$116.43
|
| Rate for Payer: Fidelis Medicare |
$64.68
|
| Rate for Payer: Galaxy Health Commercial |
$105.11
|
| Rate for Payer: Hamaspik Choice Medicare |
$64.68
|
| Rate for Payer: Humana Medicare |
$64.68
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$113.20
|
| Rate for Payer: Local 1199SEIU Medicare |
$74.39
|
| Rate for Payer: MVP Health Care of NY Commercial |
$121.28
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$91.04
|
| Rate for Payer: MVP Health Care of NY Medicare |
$67.92
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$24.26
|
| Rate for Payer: United Healthcare Medicare |
$64.68
|
| Rate for Payer: WellCare Medicare |
$88.94
|
|
|
PHOSPHOLIPID NEUTRALIZATION PLATELET
|
Facility
|
IP
|
$54.00
|
|
|
Service Code
|
HCPCS 85597
|
| Hospital Charge Code |
4302012
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$35.10 |
| Max. Negotiated Rate |
$35.10 |
| Rate for Payer: Cash Price |
$40.50
|
| Rate for Payer: Galaxy Health Commercial |
$35.10
|
|
|
PHOSPHOLIPID NEUTRALIZATION PLATELET
|
Facility
|
OP
|
$54.00
|
|
|
Service Code
|
HCPCS 85597
|
| Hospital Charge Code |
4302012
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.10 |
| Max. Negotiated Rate |
$43.20 |
| Rate for Payer: Aetna of NY Commercial |
$35.10
|
| Rate for Payer: Aetna of NY Medicare |
$24.84
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$21.60
|
| Rate for Payer: Cash Price |
$40.50
|
| Rate for Payer: CDPHP Medicare |
$19.98
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$32.40
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$43.20
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$43.20
|
| Rate for Payer: EmblemHealth Medicaid |
$43.20
|
| Rate for Payer: EmblemHealth Medicare |
$18.36
|
| Rate for Payer: EmblemHealth Select Care |
$32.40
|
| Rate for Payer: Fidelis Medicare |
$21.60
|
| Rate for Payer: Galaxy Health Commercial |
$35.10
|
| Rate for Payer: Hamaspik Choice Medicare |
$21.60
|
| Rate for Payer: Humana Medicare |
$21.60
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$35.10
|
| Rate for Payer: Local 1199SEIU Medicare |
$24.84
|
| Rate for Payer: MVP Health Care of NY Commercial |
$40.50
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$30.40
|
| Rate for Payer: MVP Health Care of NY Medicare |
$22.68
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$40.50
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$8.10
|
| Rate for Payer: United Healthcare Commercial |
$40.50
|
| Rate for Payer: United Healthcare Medicare |
$21.60
|
| Rate for Payer: WellCare Medicare |
$29.70
|
|
|
PHOSPHORUS
|
Facility
|
IP
|
$14.00
|
|
|
Service Code
|
HCPCS 84100
|
| Hospital Charge Code |
4300627
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$9.10 |
| Max. Negotiated Rate |
$9.10 |
| Rate for Payer: Cash Price |
$10.50
|
| Rate for Payer: Galaxy Health Commercial |
$9.10
|
|
|
PHOSPHORUS
|
Facility
|
OP
|
$14.00
|
|
|
Service Code
|
HCPCS 84100
|
| Hospital Charge Code |
4300627
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$2.10 |
| Max. Negotiated Rate |
$11.20 |
| Rate for Payer: Aetna of NY Commercial |
$9.10
|
| Rate for Payer: Aetna of NY Medicare |
$6.44
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$5.60
|
| Rate for Payer: Cash Price |
$10.50
|
| Rate for Payer: CDPHP Medicare |
$5.18
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$8.40
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$11.20
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$11.20
|
| Rate for Payer: EmblemHealth Medicaid |
$11.20
|
| Rate for Payer: EmblemHealth Medicare |
$4.76
|
| Rate for Payer: EmblemHealth Select Care |
$8.40
|
| Rate for Payer: Fidelis Medicare |
$5.60
|
| Rate for Payer: Galaxy Health Commercial |
$9.10
|
| Rate for Payer: Hamaspik Choice Medicare |
$5.60
|
| Rate for Payer: Humana Medicare |
$5.60
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$9.10
|
| Rate for Payer: Local 1199SEIU Medicare |
$6.44
|
| Rate for Payer: MVP Health Care of NY Commercial |
$10.50
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$7.88
|
| Rate for Payer: MVP Health Care of NY Medicare |
$5.88
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$10.50
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$2.10
|
| Rate for Payer: United Healthcare Commercial |
$10.50
|
| Rate for Payer: United Healthcare Medicare |
$5.60
|
| Rate for Payer: WellCare Medicare |
$7.70
|
|
|
PHYSICAL PERFORM TEST EA 15M
|
Facility
|
OP
|
$122.00
|
|
|
Service Code
|
HCPCS 97750 GP
|
| Hospital Charge Code |
4650051
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$18.30 |
| Max. Negotiated Rate |
$187.00 |
| Rate for Payer: Aetna of NY Commercial |
$115.00
|
| Rate for Payer: Aetna of NY Medicare |
$56.12
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$48.80
|
| Rate for Payer: Cash Price |
$91.50
|
| Rate for Payer: Cash Price |
$91.50
|
| Rate for Payer: Cash Price |
$91.50
|
| Rate for Payer: CDPHP Medicare |
$45.14
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$97.60
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$44.38
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$36.98
|
| Rate for Payer: EmblemHealth Medicaid |
$36.98
|
| Rate for Payer: EmblemHealth Medicare |
$41.48
|
| Rate for Payer: EmblemHealth Select Care |
$87.84
|
| Rate for Payer: Fidelis Medicare |
$48.80
|
| Rate for Payer: Galaxy Health Commercial |
$79.30
|
| Rate for Payer: Galaxy Health Workers Comp |
$36.24
|
| Rate for Payer: Hamaspik Choice Medicaid |
$36.98
|
| Rate for Payer: Hamaspik Choice Medicare |
$48.80
|
| Rate for Payer: Humana Medicare |
$48.80
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$115.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$56.12
|
| Rate for Payer: MVP Health Care of NY Child Health Plus/Family Health Plus/HARP/Medicaid |
$38.83
|
| Rate for Payer: MVP Health Care of NY Commercial |
$187.00
|
| Rate for Payer: MVP Health Care of NY Essential Plan 1&2 |
$79.51
|
| Rate for Payer: MVP Health Care of NY Essential Plan 3&4 |
$79.51
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$141.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$51.24
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$161.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$18.30
|
| Rate for Payer: United Healthcare Commercial |
$161.00
|
| Rate for Payer: United Healthcare Medicare |
$48.80
|
| Rate for Payer: WellCare Child Health Plus/Family Health Plus/Medicaid |
$38.83
|
| Rate for Payer: WellCare Medicare |
$67.10
|
|
|
PHYSICAL PERFORM TEST EA 15M
|
Facility
|
IP
|
$122.00
|
|
|
Service Code
|
HCPCS 97750 GP
|
| Hospital Charge Code |
4650051
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$79.30 |
| Max. Negotiated Rate |
$79.30 |
| Rate for Payer: Cash Price |
$91.50
|
| Rate for Payer: Galaxy Health Commercial |
$79.30
|
|
|
PHYSICAL PERFORM TEST EA 15M (MOD 59)
|
Facility
|
OP
|
$122.00
|
|
|
Service Code
|
HCPCS 97750 GP,59
|
| Hospital Charge Code |
4650384
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$18.30 |
| Max. Negotiated Rate |
$187.00 |
| Rate for Payer: Aetna of NY Commercial |
$115.00
|
| Rate for Payer: Aetna of NY Medicare |
$56.12
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$48.80
|
| Rate for Payer: Cash Price |
$91.50
|
| Rate for Payer: Cash Price |
$91.50
|
| Rate for Payer: Cash Price |
$91.50
|
| Rate for Payer: CDPHP Medicare |
$45.14
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$97.60
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$44.38
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$36.98
|
| Rate for Payer: EmblemHealth Medicaid |
$36.98
|
| Rate for Payer: EmblemHealth Medicare |
$41.48
|
| Rate for Payer: EmblemHealth Select Care |
$87.84
|
| Rate for Payer: Fidelis Medicare |
$48.80
|
| Rate for Payer: Galaxy Health Commercial |
$79.30
|
| Rate for Payer: Galaxy Health Workers Comp |
$36.24
|
| Rate for Payer: Hamaspik Choice Medicaid |
$36.98
|
| Rate for Payer: Hamaspik Choice Medicare |
$48.80
|
| Rate for Payer: Humana Medicare |
$48.80
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$115.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$56.12
|
| Rate for Payer: MVP Health Care of NY Child Health Plus/Family Health Plus/HARP/Medicaid |
$38.83
|
| Rate for Payer: MVP Health Care of NY Commercial |
$187.00
|
| Rate for Payer: MVP Health Care of NY Essential Plan 1&2 |
$79.51
|
| Rate for Payer: MVP Health Care of NY Essential Plan 3&4 |
$79.51
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$141.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$51.24
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$161.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$18.30
|
| Rate for Payer: United Healthcare Commercial |
$161.00
|
| Rate for Payer: United Healthcare Medicare |
$48.80
|
| Rate for Payer: WellCare Child Health Plus/Family Health Plus/Medicaid |
$38.83
|
| Rate for Payer: WellCare Medicare |
$67.10
|
|
|
PHYSICAL PERFORM TEST EA 15M (MOD 59)
|
Facility
|
IP
|
$122.00
|
|
|
Service Code
|
HCPCS 97750 GP,59
|
| Hospital Charge Code |
4650384
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$79.30 |
| Max. Negotiated Rate |
$79.30 |
| Rate for Payer: Cash Price |
$91.50
|
| Rate for Payer: Galaxy Health Commercial |
$79.30
|
|
|
PHYSICAL PERFORM TEST EA 15M (MOD 59 W KX)
|
Facility
|
OP
|
$122.00
|
|
|
Service Code
|
HCPCS 97750 GP,59,KX
|
| Hospital Charge Code |
4650436
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$18.30 |
| Max. Negotiated Rate |
$187.00 |
| Rate for Payer: Aetna of NY Commercial |
$115.00
|
| Rate for Payer: Aetna of NY Medicare |
$56.12
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$48.80
|
| Rate for Payer: Cash Price |
$91.50
|
| Rate for Payer: Cash Price |
$91.50
|
| Rate for Payer: Cash Price |
$91.50
|
| Rate for Payer: CDPHP Medicare |
$45.14
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$97.60
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$44.38
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$36.98
|
| Rate for Payer: EmblemHealth Medicaid |
$36.98
|
| Rate for Payer: EmblemHealth Medicare |
$41.48
|
| Rate for Payer: EmblemHealth Select Care |
$87.84
|
| Rate for Payer: Fidelis Medicare |
$48.80
|
| Rate for Payer: Galaxy Health Commercial |
$79.30
|
| Rate for Payer: Galaxy Health Workers Comp |
$36.24
|
| Rate for Payer: Hamaspik Choice Medicaid |
$36.98
|
| Rate for Payer: Hamaspik Choice Medicare |
$48.80
|
| Rate for Payer: Humana Medicare |
$48.80
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$115.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$56.12
|
| Rate for Payer: MVP Health Care of NY Child Health Plus/Family Health Plus/HARP/Medicaid |
$38.83
|
| Rate for Payer: MVP Health Care of NY Commercial |
$187.00
|
| Rate for Payer: MVP Health Care of NY Essential Plan 1&2 |
$79.51
|
| Rate for Payer: MVP Health Care of NY Essential Plan 3&4 |
$79.51
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$141.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$51.24
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$161.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$18.30
|
| Rate for Payer: United Healthcare Commercial |
$161.00
|
| Rate for Payer: United Healthcare Medicare |
$48.80
|
| Rate for Payer: WellCare Child Health Plus/Family Health Plus/Medicaid |
$38.83
|
| Rate for Payer: WellCare Medicare |
$67.10
|
|
|
PHYSICAL PERFORM TEST EA 15M (MOD 59 W KX)
|
Facility
|
IP
|
$122.00
|
|
|
Service Code
|
HCPCS 97750 GP,59,KX
|
| Hospital Charge Code |
4650436
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$79.30 |
| Max. Negotiated Rate |
$79.30 |
| Rate for Payer: Cash Price |
$91.50
|
| Rate for Payer: Galaxy Health Commercial |
$79.30
|
|
|
PHYSICAL PERFORM TEST EA 15M (W/ KX)
|
Facility
|
IP
|
$122.00
|
|
|
Service Code
|
HCPCS 97750 GP,KX
|
| Hospital Charge Code |
4650329
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$79.30 |
| Max. Negotiated Rate |
$79.30 |
| Rate for Payer: Cash Price |
$91.50
|
| Rate for Payer: Galaxy Health Commercial |
$79.30
|
|
|
PHYSICAL PERFORM TEST EA 15M (W/ KX)
|
Facility
|
OP
|
$122.00
|
|
|
Service Code
|
HCPCS 97750 GP,KX
|
| Hospital Charge Code |
4650329
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$18.30 |
| Max. Negotiated Rate |
$187.00 |
| Rate for Payer: Aetna of NY Commercial |
$115.00
|
| Rate for Payer: Aetna of NY Medicare |
$56.12
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$48.80
|
| Rate for Payer: Cash Price |
$91.50
|
| Rate for Payer: Cash Price |
$91.50
|
| Rate for Payer: Cash Price |
$91.50
|
| Rate for Payer: CDPHP Medicare |
$45.14
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$97.60
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$44.38
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$36.98
|
| Rate for Payer: EmblemHealth Medicaid |
$36.98
|
| Rate for Payer: EmblemHealth Medicare |
$41.48
|
| Rate for Payer: EmblemHealth Select Care |
$87.84
|
| Rate for Payer: Fidelis Medicare |
$48.80
|
| Rate for Payer: Galaxy Health Commercial |
$79.30
|
| Rate for Payer: Galaxy Health Workers Comp |
$36.24
|
| Rate for Payer: Hamaspik Choice Medicaid |
$36.98
|
| Rate for Payer: Hamaspik Choice Medicare |
$48.80
|
| Rate for Payer: Humana Medicare |
$48.80
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$115.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$56.12
|
| Rate for Payer: MVP Health Care of NY Child Health Plus/Family Health Plus/HARP/Medicaid |
$38.83
|
| Rate for Payer: MVP Health Care of NY Commercial |
$187.00
|
| Rate for Payer: MVP Health Care of NY Essential Plan 1&2 |
$79.51
|
| Rate for Payer: MVP Health Care of NY Essential Plan 3&4 |
$79.51
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$141.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$51.24
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$161.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$18.30
|
| Rate for Payer: United Healthcare Commercial |
$161.00
|
| Rate for Payer: United Healthcare Medicare |
$48.80
|
| Rate for Payer: WellCare Child Health Plus/Family Health Plus/Medicaid |
$38.83
|
| Rate for Payer: WellCare Medicare |
$67.10
|
|
|
PHYTONADIONE (VITAMIN K) INJ, PER 1 MG
|
Facility
|
OP
|
$140.08
|
|
|
Service Code
|
HCPCS J3430
|
| Hospital Charge Code |
4400809
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.16 |
| Max. Negotiated Rate |
$112.06 |
| Rate for Payer: Aetna of NY Medicare |
$64.44
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$56.03
|
| Rate for Payer: Cash Price |
$105.06
|
| Rate for Payer: Cash Price |
$105.06
|
| Rate for Payer: CDPHP Medicare |
$51.83
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$3.16
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$112.06
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$112.06
|
| Rate for Payer: EmblemHealth Medicaid |
$112.06
|
| Rate for Payer: EmblemHealth Medicare |
$47.63
|
| Rate for Payer: EmblemHealth Select Care |
$3.16
|
| Rate for Payer: Fidelis Medicare |
$56.03
|
| Rate for Payer: Galaxy Health Commercial |
$91.05
|
| Rate for Payer: Hamaspik Choice Medicare |
$56.03
|
| Rate for Payer: Humana Medicare |
$56.03
|
| Rate for Payer: Local 1199SEIU Medicare |
$64.44
|
| Rate for Payer: MVP Health Care of NY Commercial |
$105.06
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$78.87
|
| Rate for Payer: MVP Health Care of NY Medicare |
$58.83
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$4.74
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$21.01
|
| Rate for Payer: United Healthcare Commercial |
$4.74
|
| Rate for Payer: United Healthcare Medicare |
$56.03
|
| Rate for Payer: WellCare Medicare |
$77.04
|
|
|
PHYTONADIONE (VITAMIN K) INJ, PER 1 MG
|
Facility
|
IP
|
$140.08
|
|
|
Service Code
|
HCPCS J3430
|
| Hospital Charge Code |
4400809
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.16 |
| Max. Negotiated Rate |
$91.05 |
| Rate for Payer: Aetna of NY Commercial |
$77.04
|
| Rate for Payer: Cash Price |
$105.06
|
| Rate for Payer: Cash Price |
$105.06
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$3.16
|
| Rate for Payer: EmblemHealth Select Care |
$3.16
|
| Rate for Payer: Galaxy Health Commercial |
$91.05
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$77.04
|
| Rate for Payer: WellCare Medicare |
$77.04
|
|
|
PICC LINE TURBO-JET PICK SET
|
Facility
|
IP
|
$581.95
|
|
| Hospital Charge Code |
4471877
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$378.27 |
| Max. Negotiated Rate |
$378.27 |
| Rate for Payer: Cash Price |
$436.46
|
| Rate for Payer: Galaxy Health Commercial |
$378.27
|
|
|
PICC LINE TURBO-JET PICK SET
|
Facility
|
OP
|
$581.95
|
|
| Hospital Charge Code |
4471877
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$87.29 |
| Max. Negotiated Rate |
$465.56 |
| Rate for Payer: Aetna of NY Commercial |
$407.37
|
| Rate for Payer: Aetna of NY Medicare |
$267.70
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$232.78
|
| Rate for Payer: Cash Price |
$436.46
|
| Rate for Payer: CDPHP Medicare |
$215.32
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$465.56
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$465.56
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$465.56
|
| Rate for Payer: EmblemHealth Medicaid |
$465.56
|
| Rate for Payer: EmblemHealth Medicare |
$197.86
|
| Rate for Payer: EmblemHealth Select Care |
$419.00
|
| Rate for Payer: Fidelis Medicare |
$232.78
|
| Rate for Payer: Galaxy Health Commercial |
$378.27
|
| Rate for Payer: Hamaspik Choice Medicare |
$232.78
|
| Rate for Payer: Humana Medicare |
$232.78
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$407.37
|
| Rate for Payer: Local 1199SEIU Medicare |
$267.70
|
| Rate for Payer: MVP Health Care of NY Commercial |
$436.46
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$327.64
|
| Rate for Payer: MVP Health Care of NY Medicare |
$244.42
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$87.29
|
| Rate for Payer: United Healthcare Medicare |
$232.78
|
| Rate for Payer: WellCare Medicare |
$320.07
|
|
|
PILOCARPINE HCL 0.01 DROP 15 ML
|
Facility
|
OP
|
$304.62
|
|
|
Service Code
|
NDC 61314020315
|
| Hospital Charge Code |
4400624
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$45.69 |
| Max. Negotiated Rate |
$243.70 |
| Rate for Payer: Aetna of NY Commercial |
$213.23
|
| Rate for Payer: Aetna of NY Medicare |
$140.13
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$121.85
|
| Rate for Payer: Cash Price |
$228.46
|
| Rate for Payer: CDPHP Medicare |
$112.71
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$243.70
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$243.70
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$243.70
|
| Rate for Payer: EmblemHealth Medicaid |
$243.70
|
| Rate for Payer: EmblemHealth Medicare |
$103.57
|
| Rate for Payer: EmblemHealth Select Care |
$219.33
|
| Rate for Payer: Fidelis Medicare |
$121.85
|
| Rate for Payer: Galaxy Health Commercial |
$198.00
|
| Rate for Payer: Hamaspik Choice Medicare |
$121.85
|
| Rate for Payer: Humana Medicare |
$121.85
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$213.23
|
| Rate for Payer: Local 1199SEIU Medicare |
$140.13
|
| Rate for Payer: MVP Health Care of NY Commercial |
$228.47
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$171.50
|
| Rate for Payer: MVP Health Care of NY Medicare |
$127.94
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$45.69
|
| Rate for Payer: United Healthcare Medicare |
$121.85
|
| Rate for Payer: WellCare Medicare |
$167.54
|
|
|
PILOCARPINE HCL 0.01 DROP 15 ML
|
Facility
|
IP
|
$304.62
|
|
|
Service Code
|
NDC 61314020315
|
| Hospital Charge Code |
4400624
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$167.54 |
| Max. Negotiated Rate |
$198.00 |
| Rate for Payer: Cash Price |
$228.46
|
| Rate for Payer: Galaxy Health Commercial |
$198.00
|
| Rate for Payer: WellCare Medicare |
$167.54
|
|
|
PIPERACILLIN/TAZOBACTAM INJ, 1 GRAM/0.125 GRAMS (1.125 GRAMS)
|
Facility
|
OP
|
$18.46
|
|
|
Service Code
|
HCPCS J2543
|
| Hospital Charge Code |
4400826
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.08 |
| Max. Negotiated Rate |
$14.77 |
| Rate for Payer: Aetna of NY Medicare |
$8.49
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$7.38
|
| Rate for Payer: Cash Price |
$13.84
|
| Rate for Payer: Cash Price |
$13.84
|
| Rate for Payer: CDPHP Medicare |
$6.83
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$1.08
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$14.77
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$14.77
|
| Rate for Payer: EmblemHealth Medicaid |
$14.77
|
| Rate for Payer: EmblemHealth Medicare |
$6.28
|
| Rate for Payer: EmblemHealth Select Care |
$1.08
|
| Rate for Payer: Fidelis Medicare |
$7.38
|
| Rate for Payer: Galaxy Health Commercial |
$12.00
|
| Rate for Payer: Hamaspik Choice Medicare |
$7.38
|
| Rate for Payer: Humana Medicare |
$7.38
|
| Rate for Payer: Local 1199SEIU Medicare |
$8.49
|
| Rate for Payer: MVP Health Care of NY Commercial |
$13.85
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$10.39
|
| Rate for Payer: MVP Health Care of NY Medicare |
$7.75
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$2.24
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$2.77
|
| Rate for Payer: United Healthcare Commercial |
$2.24
|
| Rate for Payer: United Healthcare Medicare |
$7.38
|
| Rate for Payer: WellCare Medicare |
$10.15
|
|
