|
SREP S/N/A/G/TR/E; 2.5CM/<
|
Facility
|
OP
|
$573.00
|
|
|
Service Code
|
HCPCS 12001
|
| Hospital Charge Code |
4852000
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$190.75 |
| Max. Negotiated Rate |
$2,521.93 |
| Rate for Payer: Aetna of NY Commercial |
$401.10
|
| Rate for Payer: Aetna of NY Medicare |
$263.58
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$2,017.33
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$2,521.93
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$212.01
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$286.50
|
| Rate for Payer: Cash Price |
$429.75
|
| Rate for Payer: Cash Price |
$429.75
|
| Rate for Payer: Cash Price |
$429.75
|
| Rate for Payer: CDPHP Commercial |
$461.26
|
| Rate for Payer: CDPHP Medicare |
$212.01
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$458.40
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$458.40
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$458.40
|
| Rate for Payer: EmblemHealth Medicaid |
$458.40
|
| Rate for Payer: EmblemHealth Medicare |
$194.82
|
| Rate for Payer: EmblemHealth Select Care |
$412.56
|
| Rate for Payer: Fidelis Medicare |
$218.37
|
| Rate for Payer: Galaxy Health Commercial |
$372.45
|
| Rate for Payer: Hamaspik Choice Medicare |
$212.01
|
| Rate for Payer: Humana Medicare |
$212.01
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$401.10
|
| Rate for Payer: Local 1199SEIU Medicare |
$263.58
|
| Rate for Payer: MVP Health Care of NY Commercial |
$429.75
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$322.60
|
| Rate for Payer: MVP Health Care of NY Medicare |
$222.61
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$190.75
|
| Rate for Payer: United Healthcare Medicare |
$212.01
|
| Rate for Payer: WellCare Medicare |
$315.15
|
|
|
STANDARD GRAFT JACKET
|
Facility
|
IP
|
$8,456.00
|
|
| Hospital Charge Code |
4471638
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$5,496.40 |
| Max. Negotiated Rate |
$5,496.40 |
| Rate for Payer: Cash Price |
$6,342.00
|
| Rate for Payer: Galaxy Health Commercial |
$5,496.40
|
|
|
STANDARD GRAFT JACKET
|
Facility
|
OP
|
$8,456.00
|
|
| Hospital Charge Code |
4471638
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$2,875.04 |
| Max. Negotiated Rate |
$6,807.08 |
| Rate for Payer: Aetna of NY Commercial |
$5,919.20
|
| Rate for Payer: Aetna of NY Medicare |
$3,889.76
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$6,342.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$6,342.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$3,128.72
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$4,228.00
|
| Rate for Payer: Cash Price |
$6,342.00
|
| Rate for Payer: CDPHP Commercial |
$6,807.08
|
| Rate for Payer: CDPHP Medicare |
$3,128.72
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$6,764.80
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$6,764.80
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$6,764.80
|
| Rate for Payer: EmblemHealth Medicaid |
$6,764.80
|
| Rate for Payer: EmblemHealth Medicare |
$2,875.04
|
| Rate for Payer: EmblemHealth Select Care |
$6,088.32
|
| Rate for Payer: Fidelis Medicare |
$3,222.58
|
| Rate for Payer: Galaxy Health Commercial |
$5,496.40
|
| Rate for Payer: Hamaspik Choice Medicare |
$3,128.72
|
| Rate for Payer: Humana Medicare |
$3,128.72
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$5,919.20
|
| Rate for Payer: Local 1199SEIU Medicare |
$3,889.76
|
| Rate for Payer: MVP Health Care of NY Commercial |
$6,342.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$4,760.73
|
| Rate for Payer: MVP Health Care of NY Medicare |
$3,285.16
|
| Rate for Payer: United Healthcare Medicare |
$3,128.72
|
| Rate for Payer: WellCare Medicare |
$4,650.80
|
|
|
STANDARDIZED COGNITIVE PERFORMANCE TESTING, PER HOUR
|
Facility
|
IP
|
$374.00
|
|
|
Service Code
|
HCPCS 96125 GN
|
| Hospital Charge Code |
4670259
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$243.10 |
| Max. Negotiated Rate |
$243.10 |
| Rate for Payer: Cash Price |
$280.50
|
| Rate for Payer: Galaxy Health Commercial |
$243.10
|
|
|
STANDARDIZED COGNITIVE PERFORMANCE TESTING, PER HOUR
|
Facility
|
OP
|
$374.00
|
|
|
Service Code
|
HCPCS 96125 GN
|
| Hospital Charge Code |
4670259
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$108.00 |
| Max. Negotiated Rate |
$301.07 |
| Rate for Payer: Aetna of NY Commercial |
$112.00
|
| Rate for Payer: Aetna of NY Medicare |
$172.04
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$280.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$280.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$138.38
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$108.00
|
| Rate for Payer: Cash Price |
$280.50
|
| Rate for Payer: Cash Price |
$280.50
|
| Rate for Payer: Cash Price |
$280.50
|
| Rate for Payer: CDPHP Commercial |
$301.07
|
| Rate for Payer: CDPHP Medicare |
$138.38
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$299.20
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$299.20
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$299.20
|
| Rate for Payer: EmblemHealth Medicaid |
$299.20
|
| Rate for Payer: EmblemHealth Medicare |
$127.16
|
| Rate for Payer: EmblemHealth Select Care |
$269.28
|
| Rate for Payer: Fidelis Medicare |
$142.53
|
| Rate for Payer: Galaxy Health Commercial |
$243.10
|
| Rate for Payer: Hamaspik Choice Medicare |
$138.38
|
| Rate for Payer: Humana Medicare |
$138.38
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$112.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$172.04
|
| Rate for Payer: MVP Health Care of NY Commercial |
$179.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$134.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$145.30
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$156.00
|
| Rate for Payer: United Healthcare Commercial |
$156.00
|
| Rate for Payer: United Healthcare Medicare |
$138.38
|
| Rate for Payer: WellCare Medicare |
$205.70
|
|
|
STANDARDIZED COGNITIVE PERFORMANCE TESTING, PER HOUR (MOD 59)
|
Facility
|
IP
|
$374.00
|
|
|
Service Code
|
HCPCS 96125 GN,59
|
| Hospital Charge Code |
4670297
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$243.10 |
| Max. Negotiated Rate |
$243.10 |
| Rate for Payer: Cash Price |
$280.50
|
| Rate for Payer: Galaxy Health Commercial |
$243.10
|
|
|
STANDARDIZED COGNITIVE PERFORMANCE TESTING, PER HOUR (MOD 59)
|
Facility
|
OP
|
$374.00
|
|
|
Service Code
|
HCPCS 96125 GN,59
|
| Hospital Charge Code |
4670297
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$108.00 |
| Max. Negotiated Rate |
$301.07 |
| Rate for Payer: Aetna of NY Commercial |
$112.00
|
| Rate for Payer: Aetna of NY Medicare |
$172.04
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$280.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$280.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$138.38
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$108.00
|
| Rate for Payer: Cash Price |
$280.50
|
| Rate for Payer: Cash Price |
$280.50
|
| Rate for Payer: Cash Price |
$280.50
|
| Rate for Payer: CDPHP Commercial |
$301.07
|
| Rate for Payer: CDPHP Medicare |
$138.38
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$299.20
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$299.20
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$299.20
|
| Rate for Payer: EmblemHealth Medicaid |
$299.20
|
| Rate for Payer: EmblemHealth Medicare |
$127.16
|
| Rate for Payer: EmblemHealth Select Care |
$269.28
|
| Rate for Payer: Fidelis Medicare |
$142.53
|
| Rate for Payer: Galaxy Health Commercial |
$243.10
|
| Rate for Payer: Hamaspik Choice Medicare |
$138.38
|
| Rate for Payer: Humana Medicare |
$138.38
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$112.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$172.04
|
| Rate for Payer: MVP Health Care of NY Commercial |
$179.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$134.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$145.30
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$156.00
|
| Rate for Payer: United Healthcare Commercial |
$156.00
|
| Rate for Payer: United Healthcare Medicare |
$138.38
|
| Rate for Payer: WellCare Medicare |
$205.70
|
|
|
STANDARDIZED COGNITIVE PERFORMANCE TESTING, PER HOUR (MOD 59 W KX)
|
Facility
|
OP
|
$374.00
|
|
|
Service Code
|
HCPCS 96125 GN,59,KX
|
| Hospital Charge Code |
4670313
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$108.00 |
| Max. Negotiated Rate |
$301.07 |
| Rate for Payer: Aetna of NY Commercial |
$112.00
|
| Rate for Payer: Aetna of NY Medicare |
$172.04
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$280.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$280.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$138.38
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$108.00
|
| Rate for Payer: Cash Price |
$280.50
|
| Rate for Payer: Cash Price |
$280.50
|
| Rate for Payer: Cash Price |
$280.50
|
| Rate for Payer: CDPHP Commercial |
$301.07
|
| Rate for Payer: CDPHP Medicare |
$138.38
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$299.20
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$299.20
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$299.20
|
| Rate for Payer: EmblemHealth Medicaid |
$299.20
|
| Rate for Payer: EmblemHealth Medicare |
$127.16
|
| Rate for Payer: EmblemHealth Select Care |
$269.28
|
| Rate for Payer: Fidelis Medicare |
$142.53
|
| Rate for Payer: Galaxy Health Commercial |
$243.10
|
| Rate for Payer: Hamaspik Choice Medicare |
$138.38
|
| Rate for Payer: Humana Medicare |
$138.38
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$112.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$172.04
|
| Rate for Payer: MVP Health Care of NY Commercial |
$179.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$134.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$145.30
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$156.00
|
| Rate for Payer: United Healthcare Commercial |
$156.00
|
| Rate for Payer: United Healthcare Medicare |
$138.38
|
| Rate for Payer: WellCare Medicare |
$205.70
|
|
|
STANDARDIZED COGNITIVE PERFORMANCE TESTING, PER HOUR (MOD 59 W KX)
|
Facility
|
IP
|
$374.00
|
|
|
Service Code
|
HCPCS 96125 GN,59,KX
|
| Hospital Charge Code |
4670313
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$243.10 |
| Max. Negotiated Rate |
$243.10 |
| Rate for Payer: Cash Price |
$280.50
|
| Rate for Payer: Galaxy Health Commercial |
$243.10
|
|
|
STANDARDIZED COGNITIVE PERFORMANCE TESTING, PER HOUR (W/ KX)
|
Facility
|
OP
|
$374.00
|
|
|
Service Code
|
HCPCS 96125 GN,KX
|
| Hospital Charge Code |
4670275
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$108.00 |
| Max. Negotiated Rate |
$301.07 |
| Rate for Payer: Aetna of NY Commercial |
$112.00
|
| Rate for Payer: Aetna of NY Medicare |
$172.04
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$280.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$280.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$138.38
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$108.00
|
| Rate for Payer: Cash Price |
$280.50
|
| Rate for Payer: Cash Price |
$280.50
|
| Rate for Payer: Cash Price |
$280.50
|
| Rate for Payer: CDPHP Commercial |
$301.07
|
| Rate for Payer: CDPHP Medicare |
$138.38
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$299.20
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$299.20
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$299.20
|
| Rate for Payer: EmblemHealth Medicaid |
$299.20
|
| Rate for Payer: EmblemHealth Medicare |
$127.16
|
| Rate for Payer: EmblemHealth Select Care |
$269.28
|
| Rate for Payer: Fidelis Medicare |
$142.53
|
| Rate for Payer: Galaxy Health Commercial |
$243.10
|
| Rate for Payer: Hamaspik Choice Medicare |
$138.38
|
| Rate for Payer: Humana Medicare |
$138.38
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$112.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$172.04
|
| Rate for Payer: MVP Health Care of NY Commercial |
$179.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$134.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$145.30
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$156.00
|
| Rate for Payer: United Healthcare Commercial |
$156.00
|
| Rate for Payer: United Healthcare Medicare |
$138.38
|
| Rate for Payer: WellCare Medicare |
$205.70
|
|
|
STANDARDIZED COGNITIVE PERFORMANCE TESTING, PER HOUR (W/ KX)
|
Facility
|
IP
|
$374.00
|
|
|
Service Code
|
HCPCS 96125 GN,KX
|
| Hospital Charge Code |
4670275
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$243.10 |
| Max. Negotiated Rate |
$243.10 |
| Rate for Payer: Cash Price |
$280.50
|
| Rate for Payer: Galaxy Health Commercial |
$243.10
|
|
|
STAPLER SKIN PRECISE SYSTEM
|
Facility
|
OP
|
$14.00
|
|
| Hospital Charge Code |
4472001
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$4.76 |
| Max. Negotiated Rate |
$11.27 |
| Rate for Payer: Aetna of NY Commercial |
$9.80
|
| Rate for Payer: Aetna of NY Medicare |
$6.44
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$10.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$10.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$5.18
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$7.00
|
| Rate for Payer: Cash Price |
$10.50
|
| Rate for Payer: CDPHP Commercial |
$11.27
|
| Rate for Payer: CDPHP Medicare |
$5.18
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$11.20
|
| 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 |
$10.08
|
| Rate for Payer: Fidelis Medicare |
$5.34
|
| Rate for Payer: Galaxy Health Commercial |
$9.10
|
| Rate for Payer: Hamaspik Choice Medicare |
$5.18
|
| Rate for Payer: Humana Medicare |
$5.18
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$9.80
|
| 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 |
$5.44
|
| Rate for Payer: United Healthcare Medicare |
$5.18
|
| Rate for Payer: WellCare Medicare |
$7.70
|
|
|
STAPLER SKIN PRECISE SYSTEM
|
Facility
|
IP
|
$14.00
|
|
| Hospital Charge Code |
4472001
|
|
Hospital Revenue Code
|
270
|
| 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
|
|
|
STERILE 10IN STOCKINETTE
|
Facility
|
OP
|
$13.00
|
|
| Hospital Charge Code |
4471192
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$4.42 |
| Max. Negotiated Rate |
$10.46 |
| Rate for Payer: Aetna of NY Commercial |
$9.10
|
| Rate for Payer: Aetna of NY Medicare |
$5.98
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$9.75
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$9.75
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$4.81
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$6.50
|
| Rate for Payer: Cash Price |
$9.75
|
| Rate for Payer: CDPHP Commercial |
$10.46
|
| Rate for Payer: CDPHP Medicare |
$4.81
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$10.40
|
| 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 |
$9.36
|
| Rate for Payer: Fidelis Medicare |
$4.95
|
| Rate for Payer: Galaxy Health Commercial |
$8.45
|
| Rate for Payer: Hamaspik Choice Medicare |
$4.81
|
| Rate for Payer: Humana Medicare |
$4.81
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$9.10
|
| 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 |
$5.05
|
| Rate for Payer: United Healthcare Medicare |
$4.81
|
| Rate for Payer: WellCare Medicare |
$7.15
|
|
|
STERILE 10IN STOCKINETTE
|
Facility
|
IP
|
$13.00
|
|
| Hospital Charge Code |
4471192
|
|
Hospital Revenue Code
|
270
|
| 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
|
|
|
STERILE 3IN STOCKINETTE
|
Facility
|
OP
|
$13.00
|
|
| Hospital Charge Code |
4471191
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$4.42 |
| Max. Negotiated Rate |
$10.46 |
| Rate for Payer: Aetna of NY Commercial |
$9.10
|
| Rate for Payer: Aetna of NY Medicare |
$5.98
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$9.75
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$9.75
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$4.81
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$6.50
|
| Rate for Payer: Cash Price |
$9.75
|
| Rate for Payer: CDPHP Commercial |
$10.46
|
| Rate for Payer: CDPHP Medicare |
$4.81
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$10.40
|
| 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 |
$9.36
|
| Rate for Payer: Fidelis Medicare |
$4.95
|
| Rate for Payer: Galaxy Health Commercial |
$8.45
|
| Rate for Payer: Hamaspik Choice Medicare |
$4.81
|
| Rate for Payer: Humana Medicare |
$4.81
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$9.10
|
| 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 |
$5.05
|
| Rate for Payer: United Healthcare Medicare |
$4.81
|
| Rate for Payer: WellCare Medicare |
$7.15
|
|
|
STERILE 3IN STOCKINETTE
|
Facility
|
IP
|
$13.00
|
|
| Hospital Charge Code |
4471191
|
|
Hospital Revenue Code
|
270
|
| 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
|
|
|
STERILE 8IN STOCKINETTE
|
Facility
|
OP
|
$25.00
|
|
| Hospital Charge Code |
4471193
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$8.50 |
| Max. Negotiated Rate |
$20.12 |
| Rate for Payer: Aetna of NY Commercial |
$17.50
|
| Rate for Payer: Aetna of NY Medicare |
$11.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$18.75
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$18.75
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$9.25
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$12.50
|
| Rate for Payer: Cash Price |
$18.75
|
| Rate for Payer: CDPHP Commercial |
$20.12
|
| Rate for Payer: CDPHP Medicare |
$9.25
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$20.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$20.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$20.00
|
| Rate for Payer: EmblemHealth Medicaid |
$20.00
|
| Rate for Payer: EmblemHealth Medicare |
$8.50
|
| Rate for Payer: EmblemHealth Select Care |
$18.00
|
| Rate for Payer: Fidelis Medicare |
$9.53
|
| Rate for Payer: Galaxy Health Commercial |
$16.25
|
| Rate for Payer: Hamaspik Choice Medicare |
$9.25
|
| Rate for Payer: Humana Medicare |
$9.25
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$17.50
|
| Rate for Payer: Local 1199SEIU Medicare |
$11.50
|
| Rate for Payer: MVP Health Care of NY Commercial |
$18.75
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$14.08
|
| Rate for Payer: MVP Health Care of NY Medicare |
$9.71
|
| Rate for Payer: United Healthcare Medicare |
$9.25
|
| Rate for Payer: WellCare Medicare |
$13.75
|
|
|
STERILE 8IN STOCKINETTE
|
Facility
|
IP
|
$25.00
|
|
| Hospital Charge Code |
4471193
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$16.25 |
| Max. Negotiated Rate |
$16.25 |
| Rate for Payer: Cash Price |
$18.75
|
| Rate for Payer: Galaxy Health Commercial |
$16.25
|
|
|
STERILE DRAPE-61050
|
Facility
|
IP
|
$23.00
|
|
| Hospital Charge Code |
4479225
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$14.95 |
| Max. Negotiated Rate |
$14.95 |
| Rate for Payer: Cash Price |
$17.25
|
| Rate for Payer: Galaxy Health Commercial |
$14.95
|
|
|
STERILE DRAPE-61050
|
Facility
|
OP
|
$23.00
|
|
| Hospital Charge Code |
4479225
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$7.82 |
| Max. Negotiated Rate |
$18.52 |
| Rate for Payer: Aetna of NY Commercial |
$16.10
|
| Rate for Payer: Aetna of NY Medicare |
$10.58
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$17.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$17.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$8.51
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$11.50
|
| Rate for Payer: Cash Price |
$17.25
|
| Rate for Payer: CDPHP Commercial |
$18.52
|
| Rate for Payer: CDPHP Medicare |
$8.51
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$18.40
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$18.40
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$18.40
|
| Rate for Payer: EmblemHealth Medicaid |
$18.40
|
| Rate for Payer: EmblemHealth Medicare |
$7.82
|
| Rate for Payer: EmblemHealth Select Care |
$16.56
|
| Rate for Payer: Fidelis Medicare |
$8.77
|
| Rate for Payer: Galaxy Health Commercial |
$14.95
|
| Rate for Payer: Hamaspik Choice Medicare |
$8.51
|
| Rate for Payer: Humana Medicare |
$8.51
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$16.10
|
| Rate for Payer: Local 1199SEIU Medicare |
$10.58
|
| Rate for Payer: MVP Health Care of NY Commercial |
$17.25
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$12.95
|
| Rate for Payer: MVP Health Care of NY Medicare |
$8.94
|
| Rate for Payer: United Healthcare Medicare |
$8.51
|
| Rate for Payer: WellCare Medicare |
$12.65
|
|
|
STERILE WATER 1000 ML
|
Facility
|
IP
|
$19.57
|
|
|
Service Code
|
NDC 00409713909
|
| Hospital Charge Code |
4450041
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$12.72 |
| Max. Negotiated Rate |
$12.72 |
| Rate for Payer: Cash Price |
$14.68
|
| Rate for Payer: Galaxy Health Commercial |
$12.72
|
|
|
STERILE WATER 1000 ML
|
Facility
|
OP
|
$19.57
|
|
|
Service Code
|
NDC 00409713909
|
| Hospital Charge Code |
4450041
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$6.65 |
| Max. Negotiated Rate |
$15.75 |
| Rate for Payer: Aetna of NY Commercial |
$13.70
|
| Rate for Payer: Aetna of NY Medicare |
$9.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$14.68
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$14.68
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$7.24
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$9.78
|
| Rate for Payer: Cash Price |
$14.68
|
| Rate for Payer: CDPHP Commercial |
$15.75
|
| Rate for Payer: CDPHP Medicare |
$7.24
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$15.66
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$15.66
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$15.66
|
| Rate for Payer: EmblemHealth Medicaid |
$15.66
|
| Rate for Payer: EmblemHealth Medicare |
$6.65
|
| Rate for Payer: EmblemHealth Select Care |
$14.09
|
| Rate for Payer: Fidelis Medicare |
$7.46
|
| Rate for Payer: Galaxy Health Commercial |
$12.72
|
| Rate for Payer: Hamaspik Choice Medicare |
$7.24
|
| Rate for Payer: Humana Medicare |
$7.24
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$13.70
|
| Rate for Payer: Local 1199SEIU Medicare |
$9.00
|
| Rate for Payer: MVP Health Care of NY Commercial |
$14.68
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$11.02
|
| Rate for Payer: MVP Health Care of NY Medicare |
$7.60
|
| Rate for Payer: United Healthcare Medicare |
$7.24
|
| Rate for Payer: WellCare Medicare |
$10.76
|
|
|
STIRRUPS-52710
|
Facility
|
IP
|
$15.00
|
|
| Hospital Charge Code |
4479226
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$9.75 |
| Max. Negotiated Rate |
$9.75 |
| Rate for Payer: Cash Price |
$11.25
|
| Rate for Payer: Galaxy Health Commercial |
$9.75
|
|
|
STIRRUPS-52710
|
Facility
|
OP
|
$15.00
|
|
| Hospital Charge Code |
4479226
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$5.10 |
| Max. Negotiated Rate |
$12.08 |
| Rate for Payer: Aetna of NY Commercial |
$10.50
|
| Rate for Payer: Aetna of NY Medicare |
$6.90
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$11.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$11.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$5.55
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$7.50
|
| Rate for Payer: Cash Price |
$11.25
|
| Rate for Payer: CDPHP Commercial |
$12.08
|
| Rate for Payer: CDPHP Medicare |
$5.55
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$12.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$12.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$12.00
|
| Rate for Payer: EmblemHealth Medicaid |
$12.00
|
| Rate for Payer: EmblemHealth Medicare |
$5.10
|
| Rate for Payer: EmblemHealth Select Care |
$10.80
|
| Rate for Payer: Fidelis Medicare |
$5.72
|
| Rate for Payer: Galaxy Health Commercial |
$9.75
|
| Rate for Payer: Hamaspik Choice Medicare |
$5.55
|
| Rate for Payer: Humana Medicare |
$5.55
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$10.50
|
| Rate for Payer: Local 1199SEIU Medicare |
$6.90
|
| Rate for Payer: MVP Health Care of NY Commercial |
$11.25
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$8.44
|
| Rate for Payer: MVP Health Care of NY Medicare |
$5.83
|
| Rate for Payer: United Healthcare Medicare |
$5.55
|
| Rate for Payer: WellCare Medicare |
$8.25
|
|
