|
STRESS TTE ONLY
|
Facility
|
IP
|
$1,579.00
|
|
|
Service Code
|
HCPCS 93350
|
| Hospital Charge Code |
4480010
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$1,026.35 |
| Max. Negotiated Rate |
$1,026.35 |
| Rate for Payer: Cash Price |
$1,184.25
|
| Rate for Payer: Galaxy Health Commercial |
$1,026.35
|
|
|
STRIP IODOFORM PAC 1/2X5YD
|
Facility
|
IP
|
$13.00
|
|
| Hospital Charge Code |
4471650
|
|
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
|
|
|
STRIP IODOFORM PAC 1/2X5YD
|
Facility
|
OP
|
$13.00
|
|
| Hospital Charge Code |
4471650
|
|
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
|
|
|
STRIP IODOFORM PAC 1/4X5YD
|
Facility
|
OP
|
$11.00
|
|
| Hospital Charge Code |
4471649
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$3.74 |
| Max. Negotiated Rate |
$8.86 |
| Rate for Payer: Aetna of NY Commercial |
$7.70
|
| Rate for Payer: Aetna of NY Medicare |
$5.06
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$8.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$8.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$4.07
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$5.50
|
| Rate for Payer: Cash Price |
$8.25
|
| Rate for Payer: CDPHP Commercial |
$8.86
|
| Rate for Payer: CDPHP Medicare |
$4.07
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$8.80
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$8.80
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$8.80
|
| Rate for Payer: EmblemHealth Medicaid |
$8.80
|
| Rate for Payer: EmblemHealth Medicare |
$3.74
|
| Rate for Payer: EmblemHealth Select Care |
$7.92
|
| Rate for Payer: Fidelis Medicare |
$4.19
|
| Rate for Payer: Galaxy Health Commercial |
$7.15
|
| Rate for Payer: Hamaspik Choice Medicare |
$4.07
|
| Rate for Payer: Humana Medicare |
$4.07
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$7.70
|
| Rate for Payer: Local 1199SEIU Medicare |
$5.06
|
| Rate for Payer: MVP Health Care of NY Commercial |
$8.25
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$6.19
|
| Rate for Payer: MVP Health Care of NY Medicare |
$4.27
|
| Rate for Payer: United Healthcare Medicare |
$4.07
|
| Rate for Payer: WellCare Medicare |
$6.05
|
|
|
STRIP IODOFORM PAC 1/4X5YD
|
Facility
|
IP
|
$11.00
|
|
| Hospital Charge Code |
4471649
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$7.15 |
| Max. Negotiated Rate |
$7.15 |
| Rate for Payer: Cash Price |
$8.25
|
| Rate for Payer: Galaxy Health Commercial |
$7.15
|
|
|
STRIP IODOFORM PAC 1"X5YD
|
Facility
|
IP
|
$14.00
|
|
| Hospital Charge Code |
4471651
|
|
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
|
|
|
STRIP IODOFORM PAC 1"X5YD
|
Facility
|
OP
|
$14.00
|
|
| Hospital Charge Code |
4471651
|
|
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
|
|
|
STRIP IODOFORM PAC 2"X5YD
|
Facility
|
IP
|
$19.00
|
|
| Hospital Charge Code |
4471652
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$12.35 |
| Max. Negotiated Rate |
$12.35 |
| Rate for Payer: Cash Price |
$14.25
|
| Rate for Payer: Galaxy Health Commercial |
$12.35
|
|
|
STRIP IODOFORM PAC 2"X5YD
|
Facility
|
OP
|
$19.00
|
|
| Hospital Charge Code |
4471652
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$6.46 |
| Max. Negotiated Rate |
$15.30 |
| Rate for Payer: Aetna of NY Commercial |
$13.30
|
| Rate for Payer: Aetna of NY Medicare |
$8.74
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$14.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$14.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$7.03
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$9.50
|
| Rate for Payer: Cash Price |
$14.25
|
| Rate for Payer: CDPHP Commercial |
$15.30
|
| Rate for Payer: CDPHP Medicare |
$7.03
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$15.20
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$15.20
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$15.20
|
| Rate for Payer: EmblemHealth Medicaid |
$15.20
|
| Rate for Payer: EmblemHealth Medicare |
$6.46
|
| Rate for Payer: EmblemHealth Select Care |
$13.68
|
| Rate for Payer: Fidelis Medicare |
$7.24
|
| Rate for Payer: Galaxy Health Commercial |
$12.35
|
| Rate for Payer: Hamaspik Choice Medicare |
$7.03
|
| Rate for Payer: Humana Medicare |
$7.03
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$13.30
|
| Rate for Payer: Local 1199SEIU Medicare |
$8.74
|
| Rate for Payer: MVP Health Care of NY Commercial |
$14.25
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$10.70
|
| Rate for Payer: MVP Health Care of NY Medicare |
$7.38
|
| Rate for Payer: United Healthcare Medicare |
$7.03
|
| Rate for Payer: WellCare Medicare |
$10.45
|
|
|
STRYKEFLOW II W/ TIP SUC/IRR
|
Facility
|
IP
|
$330.00
|
|
| Hospital Charge Code |
4471233
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$214.50 |
| Max. Negotiated Rate |
$214.50 |
| Rate for Payer: Cash Price |
$247.50
|
| Rate for Payer: Galaxy Health Commercial |
$214.50
|
|
|
STRYKEFLOW II W/ TIP SUC/IRR
|
Facility
|
OP
|
$330.00
|
|
| Hospital Charge Code |
4471233
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$112.20 |
| Max. Negotiated Rate |
$265.65 |
| Rate for Payer: Aetna of NY Commercial |
$231.00
|
| Rate for Payer: Aetna of NY Medicare |
$151.80
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$247.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$247.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$122.10
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$165.00
|
| Rate for Payer: Cash Price |
$247.50
|
| Rate for Payer: CDPHP Commercial |
$265.65
|
| Rate for Payer: CDPHP Medicare |
$122.10
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$264.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$264.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$264.00
|
| Rate for Payer: EmblemHealth Medicaid |
$264.00
|
| Rate for Payer: EmblemHealth Medicare |
$112.20
|
| Rate for Payer: EmblemHealth Select Care |
$237.60
|
| Rate for Payer: Fidelis Medicare |
$125.76
|
| Rate for Payer: Galaxy Health Commercial |
$214.50
|
| Rate for Payer: Hamaspik Choice Medicare |
$122.10
|
| Rate for Payer: Humana Medicare |
$122.10
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$231.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$151.80
|
| Rate for Payer: MVP Health Care of NY Commercial |
$247.50
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$185.79
|
| Rate for Payer: MVP Health Care of NY Medicare |
$128.20
|
| Rate for Payer: United Healthcare Medicare |
$122.10
|
| Rate for Payer: WellCare Medicare |
$181.50
|
|
|
STRYKER BATTERY PACK 9.6V
|
Facility
|
IP
|
$1,504.00
|
|
| Hospital Charge Code |
4471353
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$977.60 |
| Max. Negotiated Rate |
$977.60 |
| Rate for Payer: Cash Price |
$1,128.00
|
| Rate for Payer: Galaxy Health Commercial |
$977.60
|
|
|
STRYKER BATTERY PACK 9.6V
|
Facility
|
OP
|
$1,504.00
|
|
| Hospital Charge Code |
4471353
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$511.36 |
| Max. Negotiated Rate |
$1,210.72 |
| Rate for Payer: Aetna of NY Commercial |
$1,052.80
|
| Rate for Payer: Aetna of NY Medicare |
$691.84
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$1,128.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$1,128.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$556.48
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$752.00
|
| Rate for Payer: Cash Price |
$1,128.00
|
| Rate for Payer: CDPHP Commercial |
$1,210.72
|
| Rate for Payer: CDPHP Medicare |
$556.48
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$1,203.20
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$1,203.20
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$1,203.20
|
| Rate for Payer: EmblemHealth Medicaid |
$1,203.20
|
| Rate for Payer: EmblemHealth Medicare |
$511.36
|
| Rate for Payer: EmblemHealth Select Care |
$1,082.88
|
| Rate for Payer: Fidelis Medicare |
$573.17
|
| Rate for Payer: Galaxy Health Commercial |
$977.60
|
| Rate for Payer: Hamaspik Choice Medicare |
$556.48
|
| Rate for Payer: Humana Medicare |
$556.48
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,052.80
|
| Rate for Payer: Local 1199SEIU Medicare |
$691.84
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,128.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$846.75
|
| Rate for Payer: MVP Health Care of NY Medicare |
$584.30
|
| Rate for Payer: United Healthcare Medicare |
$556.48
|
| Rate for Payer: WellCare Medicare |
$827.20
|
|
|
STRYKER CUTTING BLADE
|
Facility
|
IP
|
$110.00
|
|
| Hospital Charge Code |
4479160
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$71.50 |
| Max. Negotiated Rate |
$71.50 |
| Rate for Payer: Cash Price |
$82.50
|
| Rate for Payer: Galaxy Health Commercial |
$71.50
|
|
|
STRYKER CUTTING BLADE
|
Facility
|
OP
|
$110.00
|
|
| Hospital Charge Code |
4479160
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$37.40 |
| Max. Negotiated Rate |
$88.55 |
| Rate for Payer: Aetna of NY Commercial |
$77.00
|
| Rate for Payer: Aetna of NY Medicare |
$50.60
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$82.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$82.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$40.70
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$55.00
|
| Rate for Payer: Cash Price |
$82.50
|
| Rate for Payer: CDPHP Commercial |
$88.55
|
| Rate for Payer: CDPHP Medicare |
$40.70
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$88.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$88.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$88.00
|
| Rate for Payer: EmblemHealth Medicaid |
$88.00
|
| Rate for Payer: EmblemHealth Medicare |
$37.40
|
| Rate for Payer: EmblemHealth Select Care |
$79.20
|
| Rate for Payer: Fidelis Medicare |
$41.92
|
| Rate for Payer: Galaxy Health Commercial |
$71.50
|
| Rate for Payer: Hamaspik Choice Medicare |
$40.70
|
| Rate for Payer: Humana Medicare |
$40.70
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$77.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$50.60
|
| Rate for Payer: MVP Health Care of NY Commercial |
$82.50
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$61.93
|
| Rate for Payer: MVP Health Care of NY Medicare |
$42.74
|
| Rate for Payer: United Healthcare Medicare |
$40.70
|
| Rate for Payer: WellCare Medicare |
$60.50
|
|
|
SUBOXONE 12 MG-3 MG SL FILM 1 ea, 30 eaches
|
Facility
|
OP
|
$60.00
|
|
|
Service Code
|
HCPCS J0575
|
| Hospital Charge Code |
4401342
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.39 |
| Max. Negotiated Rate |
$48.30 |
| Rate for Payer: Aetna of NY Commercial |
$33.00
|
| Rate for Payer: Aetna of NY Medicare |
$27.60
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$27.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$27.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$22.20
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$30.00
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: CDPHP Commercial |
$48.30
|
| Rate for Payer: CDPHP Medicare |
$22.20
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$48.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$48.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$48.00
|
| Rate for Payer: EmblemHealth Medicaid |
$48.00
|
| Rate for Payer: EmblemHealth Medicare |
$20.40
|
| Rate for Payer: EmblemHealth Select Care |
$43.20
|
| Rate for Payer: Fidelis Medicare |
$22.87
|
| Rate for Payer: Galaxy Health Commercial |
$39.00
|
| Rate for Payer: Hamaspik Choice Medicare |
$22.20
|
| Rate for Payer: Humana Medicare |
$22.20
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$33.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$27.60
|
| Rate for Payer: MVP Health Care of NY Commercial |
$45.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$33.78
|
| Rate for Payer: MVP Health Care of NY Medicare |
$23.31
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$30.18
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$18.39
|
| Rate for Payer: United Healthcare Commercial |
$30.18
|
| Rate for Payer: United Healthcare Medicare |
$22.20
|
| Rate for Payer: WellCare Medicare |
$33.00
|
|
|
SUBOXONE 12 MG-3 MG SL FILM 1 ea, 30 eaches
|
Facility
|
IP
|
$60.00
|
|
|
Service Code
|
HCPCS J0575
|
| Hospital Charge Code |
4401342
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$27.00 |
| Max. Negotiated Rate |
$39.00 |
| Rate for Payer: Aetna of NY Commercial |
$33.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$27.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$27.00
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Galaxy Health Commercial |
$39.00
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$33.00
|
| Rate for Payer: WellCare Medicare |
$33.00
|
|
|
SUBOXONE 2 MG-0.5 MG SL FILM 1 ea, 30 eaches
|
Facility
|
OP
|
$17.00
|
|
|
Service Code
|
HCPCS J0574
|
| Hospital Charge Code |
4401338
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.78 |
| Max. Negotiated Rate |
$708.00 |
| Rate for Payer: Aetna of NY Commercial |
$9.35
|
| Rate for Payer: Aetna of NY Medicare |
$7.82
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$7.65
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$7.65
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Essential Plan |
$15.93
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicaid |
$7.08
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$6.29
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$8.50
|
| Rate for Payer: Cash Price |
$12.75
|
| Rate for Payer: Cash Price |
$12.75
|
| Rate for Payer: CDPHP Child Health Plus/HARP/Select Plan |
$7.08
|
| Rate for Payer: CDPHP Commercial |
$13.68
|
| Rate for Payer: CDPHP Essential Plan |
$15.93
|
| Rate for Payer: CDPHP Medicare |
$6.29
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$13.60
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$8.50
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$7.08
|
| Rate for Payer: EmblemHealth Medicaid |
$7.08
|
| Rate for Payer: EmblemHealth Medicare |
$5.78
|
| Rate for Payer: EmblemHealth Select Care |
$12.24
|
| Rate for Payer: Fidelis Child Health Plus/Essential Plan/HARP/Medicaid |
$15.93
|
| Rate for Payer: Fidelis Medicare |
$6.48
|
| Rate for Payer: Galaxy Health Commercial |
$11.05
|
| Rate for Payer: Galaxy Health Workers Comp |
$10.41
|
| Rate for Payer: Hamaspik Choice Medicaid |
$708.00
|
| Rate for Payer: Hamaspik Choice Medicare |
$6.29
|
| Rate for Payer: Humana Medicare |
$6.29
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$9.35
|
| Rate for Payer: Local 1199SEIU Medicare |
$7.82
|
| Rate for Payer: MVP Health Care of NY Child Health Plus/Family Health Plus/HARP/Medicaid |
$708.00
|
| Rate for Payer: MVP Health Care of NY Commercial |
$12.75
|
| Rate for Payer: MVP Health Care of NY Essential Plan 1&2 |
$15.22
|
| Rate for Payer: MVP Health Care of NY Essential Plan 3&4 |
$15.22
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$9.57
|
| Rate for Payer: MVP Health Care of NY Medicare |
$6.60
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$19.32
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$7.08
|
| Rate for Payer: United Healthcare Commercial |
$19.32
|
| Rate for Payer: United Healthcare Medicare |
$6.29
|
| Rate for Payer: WellCare Child Health Plus/Family Health Plus/Medicaid |
$7.43
|
| Rate for Payer: WellCare Medicare |
$9.35
|
|
|
SUBOXONE 2 MG-0.5 MG SL FILM 1 ea, 30 eaches
|
Facility
|
IP
|
$17.00
|
|
|
Service Code
|
HCPCS J0574
|
| Hospital Charge Code |
4401338
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.65 |
| Max. Negotiated Rate |
$11.05 |
| Rate for Payer: Aetna of NY Commercial |
$9.35
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$7.65
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$7.65
|
| Rate for Payer: Cash Price |
$12.75
|
| Rate for Payer: Galaxy Health Commercial |
$11.05
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$9.35
|
| Rate for Payer: WellCare Medicare |
$9.35
|
|
|
SUBOXONE 4 MG-1 MG SL FILM 1 ea, 30 eaches
|
Facility
|
IP
|
$30.00
|
|
|
Service Code
|
HCPCS J0573
|
| Hospital Charge Code |
4401341
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.50 |
| Max. Negotiated Rate |
$19.50 |
| Rate for Payer: Aetna of NY Commercial |
$16.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$13.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$13.50
|
| Rate for Payer: Cash Price |
$22.50
|
| Rate for Payer: Galaxy Health Commercial |
$19.50
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$16.50
|
| Rate for Payer: WellCare Medicare |
$16.50
|
|
|
SUBOXONE 4 MG-1 MG SL FILM 1 ea, 30 eaches
|
Facility
|
OP
|
$30.00
|
|
|
Service Code
|
HCPCS J0573
|
| Hospital Charge Code |
4401341
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.01 |
| Max. Negotiated Rate |
$501.00 |
| Rate for Payer: Aetna of NY Commercial |
$16.50
|
| Rate for Payer: Aetna of NY Medicare |
$13.80
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$13.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$13.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Essential Plan |
$11.27
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicaid |
$5.01
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$11.10
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$15.00
|
| Rate for Payer: Cash Price |
$22.50
|
| Rate for Payer: Cash Price |
$22.50
|
| Rate for Payer: CDPHP Child Health Plus/HARP/Select Plan |
$5.01
|
| Rate for Payer: CDPHP Commercial |
$24.15
|
| Rate for Payer: CDPHP Essential Plan |
$11.27
|
| Rate for Payer: CDPHP Medicare |
$11.10
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$24.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$6.01
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$5.01
|
| Rate for Payer: EmblemHealth Medicaid |
$5.01
|
| Rate for Payer: EmblemHealth Medicare |
$10.20
|
| Rate for Payer: EmblemHealth Select Care |
$21.60
|
| Rate for Payer: Fidelis Child Health Plus/Essential Plan/HARP/Medicaid |
$11.27
|
| Rate for Payer: Fidelis Medicare |
$11.43
|
| Rate for Payer: Galaxy Health Commercial |
$19.50
|
| Rate for Payer: Galaxy Health Workers Comp |
$7.36
|
| Rate for Payer: Hamaspik Choice Medicaid |
$501.00
|
| Rate for Payer: Hamaspik Choice Medicare |
$11.10
|
| Rate for Payer: Humana Medicare |
$11.10
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$16.50
|
| Rate for Payer: Local 1199SEIU Medicare |
$13.80
|
| Rate for Payer: MVP Health Care of NY Child Health Plus/Family Health Plus/HARP/Medicaid |
$501.00
|
| Rate for Payer: MVP Health Care of NY Commercial |
$22.50
|
| Rate for Payer: MVP Health Care of NY Essential Plan 1&2 |
$10.77
|
| Rate for Payer: MVP Health Care of NY Essential Plan 3&4 |
$10.77
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$16.89
|
| Rate for Payer: MVP Health Care of NY Medicare |
$11.66
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$18.63
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$5.01
|
| Rate for Payer: United Healthcare Commercial |
$18.63
|
| Rate for Payer: United Healthcare Medicare |
$11.10
|
| Rate for Payer: WellCare Child Health Plus/Family Health Plus/Medicaid |
$5.26
|
| Rate for Payer: WellCare Medicare |
$16.50
|
|
|
SUBOXONE 8 MG-2 MG SL FILM 1 ea, 30 eaches
|
Facility
|
OP
|
$30.00
|
|
|
Service Code
|
HCPCS J0574
|
| Hospital Charge Code |
4401337
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.08 |
| Max. Negotiated Rate |
$708.00 |
| Rate for Payer: Aetna of NY Commercial |
$16.50
|
| Rate for Payer: Aetna of NY Medicare |
$13.80
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$13.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$13.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Essential Plan |
$15.93
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicaid |
$7.08
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$11.10
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$15.00
|
| Rate for Payer: Cash Price |
$22.50
|
| Rate for Payer: Cash Price |
$22.50
|
| Rate for Payer: CDPHP Child Health Plus/HARP/Select Plan |
$7.08
|
| Rate for Payer: CDPHP Commercial |
$24.15
|
| Rate for Payer: CDPHP Essential Plan |
$15.93
|
| Rate for Payer: CDPHP Medicare |
$11.10
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$24.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$8.50
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$7.08
|
| Rate for Payer: EmblemHealth Medicaid |
$7.08
|
| Rate for Payer: EmblemHealth Medicare |
$10.20
|
| Rate for Payer: EmblemHealth Select Care |
$21.60
|
| Rate for Payer: Fidelis Child Health Plus/Essential Plan/HARP/Medicaid |
$15.93
|
| Rate for Payer: Fidelis Medicare |
$11.43
|
| Rate for Payer: Galaxy Health Commercial |
$19.50
|
| Rate for Payer: Galaxy Health Workers Comp |
$10.41
|
| Rate for Payer: Hamaspik Choice Medicaid |
$708.00
|
| Rate for Payer: Hamaspik Choice Medicare |
$11.10
|
| Rate for Payer: Humana Medicare |
$11.10
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$16.50
|
| Rate for Payer: Local 1199SEIU Medicare |
$13.80
|
| Rate for Payer: MVP Health Care of NY Child Health Plus/Family Health Plus/HARP/Medicaid |
$708.00
|
| Rate for Payer: MVP Health Care of NY Commercial |
$22.50
|
| Rate for Payer: MVP Health Care of NY Essential Plan 1&2 |
$15.22
|
| Rate for Payer: MVP Health Care of NY Essential Plan 3&4 |
$15.22
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$16.89
|
| Rate for Payer: MVP Health Care of NY Medicare |
$11.66
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$19.32
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$7.08
|
| Rate for Payer: United Healthcare Commercial |
$19.32
|
| Rate for Payer: United Healthcare Medicare |
$11.10
|
| Rate for Payer: WellCare Child Health Plus/Family Health Plus/Medicaid |
$7.43
|
| Rate for Payer: WellCare Medicare |
$16.50
|
|
|
SUBOXONE 8 MG-2 MG SL FILM 1 ea, 30 eaches
|
Facility
|
IP
|
$30.00
|
|
|
Service Code
|
HCPCS J0574
|
| Hospital Charge Code |
4401337
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.50 |
| Max. Negotiated Rate |
$19.50 |
| Rate for Payer: Aetna of NY Commercial |
$16.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$13.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$13.50
|
| Rate for Payer: Cash Price |
$22.50
|
| Rate for Payer: Galaxy Health Commercial |
$19.50
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$16.50
|
| Rate for Payer: WellCare Medicare |
$16.50
|
|
|
SUCCINYLCHOLINE CHLORIDE, UP TO 20 MG
|
Facility
|
OP
|
$6.91
|
|
|
Service Code
|
HCPCS J0330
|
| Hospital Charge Code |
4400675
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.72 |
| Max. Negotiated Rate |
$5.56 |
| Rate for Payer: Aetna of NY Commercial |
$3.80
|
| Rate for Payer: Aetna of NY Medicare |
$3.18
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$3.11
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$3.11
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$2.56
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$3.46
|
| Rate for Payer: Cash Price |
$5.18
|
| Rate for Payer: Cash Price |
$5.18
|
| Rate for Payer: CDPHP Commercial |
$5.56
|
| Rate for Payer: CDPHP Medicare |
$2.56
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$5.53
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$5.53
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$5.53
|
| Rate for Payer: EmblemHealth Medicaid |
$5.53
|
| Rate for Payer: EmblemHealth Medicare |
$2.35
|
| Rate for Payer: EmblemHealth Select Care |
$4.98
|
| Rate for Payer: Fidelis Medicare |
$2.63
|
| Rate for Payer: Galaxy Health Commercial |
$4.49
|
| Rate for Payer: Hamaspik Choice Medicare |
$2.56
|
| Rate for Payer: Humana Medicare |
$2.56
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$3.80
|
| Rate for Payer: Local 1199SEIU Medicare |
$3.18
|
| Rate for Payer: MVP Health Care of NY Commercial |
$5.18
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$3.89
|
| Rate for Payer: MVP Health Care of NY Medicare |
$2.68
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$2.87
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$1.72
|
| Rate for Payer: United Healthcare Commercial |
$2.87
|
| Rate for Payer: United Healthcare Medicare |
$2.56
|
| Rate for Payer: WellCare Medicare |
$3.80
|
|
|
SUCCINYLCHOLINE CHLORIDE, UP TO 20 MG
|
Facility
|
IP
|
$6.91
|
|
|
Service Code
|
HCPCS J0330
|
| Hospital Charge Code |
4400675
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.11 |
| Max. Negotiated Rate |
$4.49 |
| Rate for Payer: Aetna of NY Commercial |
$3.80
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$3.11
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$3.11
|
| Rate for Payer: Cash Price |
$5.18
|
| Rate for Payer: Galaxy Health Commercial |
$4.49
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$3.80
|
| Rate for Payer: WellCare Medicare |
$3.80
|
|
