|
SUCRALFATE 1GM TABS 10X10EA
|
Facility
|
IP
|
$6.18
|
|
|
Service Code
|
NDC 51079075301
|
| Hospital Charge Code |
4400724
|
|
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
|
|
|
SUCRALFATE 1GM TABS 10X10EA
|
Facility
|
OP
|
$6.18
|
|
|
Service Code
|
NDC 51079075301
|
| Hospital Charge Code |
4400724
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.10 |
| Max. Negotiated Rate |
$4.97 |
| Rate for Payer: Aetna of NY Commercial |
$4.33
|
| Rate for Payer: Aetna of NY Medicare |
$2.84
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$4.64
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$4.64
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$2.29
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$3.09
|
| Rate for Payer: Cash Price |
$4.64
|
| Rate for Payer: CDPHP Commercial |
$4.97
|
| Rate for Payer: CDPHP Medicare |
$2.29
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$4.94
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$4.94
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$4.94
|
| Rate for Payer: EmblemHealth Medicaid |
$4.94
|
| Rate for Payer: EmblemHealth Medicare |
$2.10
|
| Rate for Payer: EmblemHealth Select Care |
$4.45
|
| Rate for Payer: Fidelis Medicare |
$2.36
|
| Rate for Payer: Galaxy Health Commercial |
$4.02
|
| Rate for Payer: Hamaspik Choice Medicare |
$2.29
|
| Rate for Payer: Humana Medicare |
$2.29
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$4.33
|
| Rate for Payer: Local 1199SEIU Medicare |
$2.84
|
| Rate for Payer: MVP Health Care of NY Commercial |
$4.64
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$3.48
|
| Rate for Payer: MVP Health Care of NY Medicare |
$2.40
|
| Rate for Payer: United Healthcare Medicare |
$2.29
|
| Rate for Payer: WellCare Medicare |
$3.40
|
|
|
SUCRALFATE SUSP
|
Facility
|
OP
|
$24.21
|
|
|
Service Code
|
NDC 66689079050
|
| Hospital Charge Code |
4408976
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.23 |
| Max. Negotiated Rate |
$19.49 |
| Rate for Payer: Aetna of NY Commercial |
$16.95
|
| Rate for Payer: Aetna of NY Medicare |
$11.14
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$18.16
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$18.16
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$8.96
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$12.10
|
| Rate for Payer: Cash Price |
$18.16
|
| Rate for Payer: CDPHP Commercial |
$19.49
|
| Rate for Payer: CDPHP Medicare |
$8.96
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$19.37
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$19.37
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$19.37
|
| Rate for Payer: EmblemHealth Medicaid |
$19.37
|
| Rate for Payer: EmblemHealth Medicare |
$8.23
|
| Rate for Payer: EmblemHealth Select Care |
$17.43
|
| Rate for Payer: Fidelis Medicare |
$9.23
|
| Rate for Payer: Galaxy Health Commercial |
$15.74
|
| Rate for Payer: Hamaspik Choice Medicare |
$8.96
|
| Rate for Payer: Humana Medicare |
$8.96
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$16.95
|
| Rate for Payer: Local 1199SEIU Medicare |
$11.14
|
| Rate for Payer: MVP Health Care of NY Commercial |
$18.16
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$13.63
|
| Rate for Payer: MVP Health Care of NY Medicare |
$9.41
|
| Rate for Payer: United Healthcare Medicare |
$8.96
|
| Rate for Payer: WellCare Medicare |
$13.32
|
|
|
SUCRALFATE SUSP
|
Facility
|
IP
|
$24.21
|
|
|
Service Code
|
NDC 66689079050
|
| Hospital Charge Code |
4408976
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.32 |
| Max. Negotiated Rate |
$15.74 |
| Rate for Payer: Cash Price |
$18.16
|
| Rate for Payer: Galaxy Health Commercial |
$15.74
|
| Rate for Payer: WellCare Medicare |
$13.32
|
|
|
SULFACETAMIDE SODIUM 0.1 DROP 15 ML
|
Facility
|
OP
|
$188.49
|
|
|
Service Code
|
NDC 24208067004
|
| Hospital Charge Code |
4400727
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$64.09 |
| Max. Negotiated Rate |
$151.73 |
| Rate for Payer: Aetna of NY Commercial |
$131.94
|
| Rate for Payer: Aetna of NY Medicare |
$86.71
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$141.37
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$141.37
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$69.74
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$94.24
|
| Rate for Payer: Cash Price |
$141.37
|
| Rate for Payer: CDPHP Commercial |
$151.73
|
| Rate for Payer: CDPHP Medicare |
$69.74
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$150.79
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$150.79
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$150.79
|
| Rate for Payer: EmblemHealth Medicaid |
$150.79
|
| Rate for Payer: EmblemHealth Medicare |
$64.09
|
| Rate for Payer: EmblemHealth Select Care |
$135.71
|
| Rate for Payer: Fidelis Medicare |
$71.83
|
| Rate for Payer: Galaxy Health Commercial |
$122.52
|
| Rate for Payer: Hamaspik Choice Medicare |
$69.74
|
| Rate for Payer: Humana Medicare |
$69.74
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$131.94
|
| Rate for Payer: Local 1199SEIU Medicare |
$86.71
|
| Rate for Payer: MVP Health Care of NY Commercial |
$141.37
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$106.12
|
| Rate for Payer: MVP Health Care of NY Medicare |
$73.23
|
| Rate for Payer: United Healthcare Medicare |
$69.74
|
| Rate for Payer: WellCare Medicare |
$103.67
|
|
|
SULFACETAMIDE SODIUM 0.1 DROP 15 ML
|
Facility
|
IP
|
$188.49
|
|
|
Service Code
|
NDC 24208067004
|
| Hospital Charge Code |
4400727
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$103.67 |
| Max. Negotiated Rate |
$122.52 |
| Rate for Payer: Cash Price |
$141.37
|
| Rate for Payer: Galaxy Health Commercial |
$122.52
|
| Rate for Payer: WellCare Medicare |
$103.67
|
|
|
SULFAMETHOXAZOLE AND TRIMETHOPRIM
|
Facility
|
OP
|
$6.00
|
|
| Hospital Charge Code |
4408938
|
|
Hospital Revenue Code
|
250
|
| 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 |
$4.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$4.50
|
| 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 |
$4.80
|
| 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 |
$4.32
|
| 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 |
$4.50
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$3.38
|
| 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
|
|
|
SULFAMETHOXAZOLE AND TRIMETHOPRIM
|
Facility
|
IP
|
$6.00
|
|
| Hospital Charge Code |
4408938
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.30 |
| Max. Negotiated Rate |
$3.90 |
| Rate for Payer: Cash Price |
$4.50
|
| Rate for Payer: Galaxy Health Commercial |
$3.90
|
| Rate for Payer: WellCare Medicare |
$3.30
|
|
|
SULFAMETHOXAZOLE/TMP 800-160MG TABS 10X1
|
Facility
|
OP
|
$6.18
|
|
|
Service Code
|
NDC 00904272561
|
| Hospital Charge Code |
4400728
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.10 |
| Max. Negotiated Rate |
$4.97 |
| Rate for Payer: Aetna of NY Commercial |
$4.33
|
| Rate for Payer: Aetna of NY Medicare |
$2.84
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$4.64
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$4.64
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$2.29
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$3.09
|
| Rate for Payer: Cash Price |
$4.64
|
| Rate for Payer: CDPHP Commercial |
$4.97
|
| Rate for Payer: CDPHP Medicare |
$2.29
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$4.94
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$4.94
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$4.94
|
| Rate for Payer: EmblemHealth Medicaid |
$4.94
|
| Rate for Payer: EmblemHealth Medicare |
$2.10
|
| Rate for Payer: EmblemHealth Select Care |
$4.45
|
| Rate for Payer: Fidelis Medicare |
$2.36
|
| Rate for Payer: Galaxy Health Commercial |
$4.02
|
| Rate for Payer: Hamaspik Choice Medicare |
$2.29
|
| Rate for Payer: Humana Medicare |
$2.29
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$4.33
|
| Rate for Payer: Local 1199SEIU Medicare |
$2.84
|
| Rate for Payer: MVP Health Care of NY Commercial |
$4.64
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$3.48
|
| Rate for Payer: MVP Health Care of NY Medicare |
$2.40
|
| Rate for Payer: United Healthcare Medicare |
$2.29
|
| Rate for Payer: WellCare Medicare |
$3.40
|
|
|
SULFAMETHOXAZOLE/TMP 800-160MG TABS 10X1
|
Facility
|
IP
|
$6.18
|
|
|
Service Code
|
NDC 00904272561
|
| Hospital Charge Code |
4400728
|
|
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
|
|
|
SULFAMETHOXAZOLE-TMP SUSP 200 mL, 20 mL
|
Facility
|
OP
|
$30.00
|
|
|
Service Code
|
NDC 00121085340
|
| Hospital Charge Code |
4401487
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.20 |
| Max. Negotiated Rate |
$24.15 |
| Rate for Payer: Aetna of NY Commercial |
$21.00
|
| Rate for Payer: Aetna of NY Medicare |
$13.80
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$22.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$22.50
|
| 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: CDPHP Commercial |
$24.15
|
| 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 |
$24.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$24.00
|
| Rate for Payer: EmblemHealth Medicaid |
$24.00
|
| Rate for Payer: EmblemHealth Medicare |
$10.20
|
| Rate for Payer: EmblemHealth Select Care |
$21.60
|
| Rate for Payer: Fidelis Medicare |
$11.43
|
| Rate for Payer: Galaxy Health Commercial |
$19.50
|
| Rate for Payer: Hamaspik Choice Medicare |
$11.10
|
| Rate for Payer: Humana Medicare |
$11.10
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$21.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$13.80
|
| Rate for Payer: MVP Health Care of NY Commercial |
$22.50
|
| 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: United Healthcare Medicare |
$11.10
|
| Rate for Payer: WellCare Medicare |
$16.50
|
|
|
SULFAMETHOXAZOLE-TMP SUSP 200 mL, 20 mL
|
Facility
|
IP
|
$30.00
|
|
|
Service Code
|
NDC 00121085340
|
| Hospital Charge Code |
4401487
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.50 |
| Max. Negotiated Rate |
$19.50 |
| Rate for Payer: Cash Price |
$22.50
|
| Rate for Payer: Galaxy Health Commercial |
$19.50
|
| Rate for Payer: WellCare Medicare |
$16.50
|
|
|
SULFAMETHOXAZOLE/TRIMETHOPRIM INJECTION 400/80, 5 ML INJECTION
|
Facility
|
IP
|
$20.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
4401293
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.00 |
| Max. Negotiated Rate |
$13.00 |
| Rate for Payer: Aetna of NY Commercial |
$11.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$9.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$9.00
|
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Galaxy Health Commercial |
$13.00
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$11.00
|
| Rate for Payer: WellCare Medicare |
$11.00
|
|
|
SULFAMETHOXAZOLE/TRIMETHOPRIM INJECTION 400/80, 5 ML INJECTION
|
Facility
|
OP
|
$20.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
4401293
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.80 |
| Max. Negotiated Rate |
$16.10 |
| Rate for Payer: Aetna of NY Commercial |
$11.00
|
| Rate for Payer: Aetna of NY Medicare |
$9.20
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$9.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$9.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$7.40
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$10.00
|
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: CDPHP Commercial |
$16.10
|
| Rate for Payer: CDPHP Medicare |
$7.40
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$16.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$16.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$16.00
|
| Rate for Payer: EmblemHealth Medicaid |
$16.00
|
| Rate for Payer: EmblemHealth Medicare |
$6.80
|
| Rate for Payer: EmblemHealth Select Care |
$14.40
|
| Rate for Payer: Fidelis Medicare |
$7.62
|
| Rate for Payer: Galaxy Health Commercial |
$13.00
|
| Rate for Payer: Hamaspik Choice Medicare |
$7.40
|
| Rate for Payer: Humana Medicare |
$7.40
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$11.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$9.20
|
| Rate for Payer: MVP Health Care of NY Commercial |
$15.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$11.26
|
| Rate for Payer: MVP Health Care of NY Medicare |
$7.77
|
| Rate for Payer: United Healthcare Medicare |
$7.40
|
| Rate for Payer: WellCare Medicare |
$11.00
|
|
|
SUMATRIPTAN SUCCINATE INJ, 6 MG
|
Facility
|
IP
|
$96.31
|
|
|
Service Code
|
HCPCS J3030
|
| Hospital Charge Code |
4400729
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$43.34 |
| Max. Negotiated Rate |
$62.60 |
| Rate for Payer: Aetna of NY Commercial |
$52.97
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$43.34
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$43.34
|
| Rate for Payer: Cash Price |
$72.23
|
| Rate for Payer: Galaxy Health Commercial |
$62.60
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$52.97
|
| Rate for Payer: WellCare Medicare |
$52.97
|
|
|
SUMATRIPTAN SUCCINATE INJ, 6 MG
|
Facility
|
OP
|
$96.31
|
|
|
Service Code
|
HCPCS J3030
|
| Hospital Charge Code |
4400729
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$32.75 |
| Max. Negotiated Rate |
$267.37 |
| Rate for Payer: Aetna of NY Commercial |
$52.97
|
| Rate for Payer: Aetna of NY Medicare |
$44.30
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$43.34
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$43.34
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$35.63
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$48.16
|
| Rate for Payer: Cash Price |
$72.23
|
| Rate for Payer: Cash Price |
$72.23
|
| Rate for Payer: CDPHP Commercial |
$77.53
|
| Rate for Payer: CDPHP Medicare |
$35.63
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$77.05
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$77.05
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$77.05
|
| Rate for Payer: EmblemHealth Medicaid |
$77.05
|
| Rate for Payer: EmblemHealth Medicare |
$32.75
|
| Rate for Payer: EmblemHealth Select Care |
$69.34
|
| Rate for Payer: Fidelis Medicare |
$36.70
|
| Rate for Payer: Galaxy Health Commercial |
$62.60
|
| Rate for Payer: Hamaspik Choice Medicare |
$35.63
|
| Rate for Payer: Humana Medicare |
$35.63
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$52.97
|
| Rate for Payer: Local 1199SEIU Medicare |
$44.30
|
| Rate for Payer: MVP Health Care of NY Commercial |
$72.23
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$54.22
|
| Rate for Payer: MVP Health Care of NY Medicare |
$37.42
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$267.37
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$164.79
|
| Rate for Payer: United Healthcare Commercial |
$267.37
|
| Rate for Payer: United Healthcare Medicare |
$35.63
|
| Rate for Payer: WellCare Medicare |
$52.97
|
|
|
SUPER QUICK ANCHOR PLUS #212032
|
Facility
|
OP
|
$1,713.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4479268
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$582.42 |
| Max. Negotiated Rate |
$1,378.96 |
| Rate for Payer: Aetna of NY Commercial |
$1,199.10
|
| Rate for Payer: Aetna of NY Medicare |
$787.98
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$770.85
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$770.85
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$633.81
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$856.50
|
| Rate for Payer: Cash Price |
$1,284.75
|
| Rate for Payer: CDPHP Commercial |
$1,378.96
|
| Rate for Payer: CDPHP Medicare |
$633.81
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$856.50
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$1,370.40
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$1,370.40
|
| Rate for Payer: EmblemHealth Medicaid |
$1,370.40
|
| Rate for Payer: EmblemHealth Medicare |
$582.42
|
| Rate for Payer: EmblemHealth Select Care |
$856.50
|
| Rate for Payer: Fidelis Medicare |
$652.82
|
| Rate for Payer: Galaxy Health Commercial |
$1,113.45
|
| Rate for Payer: Hamaspik Choice Medicare |
$633.81
|
| Rate for Payer: Humana Medicare |
$633.81
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,199.10
|
| Rate for Payer: Local 1199SEIU Medicare |
$787.98
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,113.45
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$1,113.45
|
| Rate for Payer: MVP Health Care of NY Medicare |
$665.50
|
| Rate for Payer: United Healthcare Medicare |
$633.81
|
| Rate for Payer: WellCare Medicare |
$942.15
|
|
|
SUPER QUICK ANCHOR PLUS #212032
|
Facility
|
IP
|
$1,713.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4479268
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$770.85 |
| Max. Negotiated Rate |
$1,199.10 |
| Rate for Payer: Aetna of NY Commercial |
$1,199.10
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$770.85
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$770.85
|
| Rate for Payer: Cash Price |
$1,284.75
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$856.50
|
| Rate for Payer: EmblemHealth Select Care |
$856.50
|
| Rate for Payer: Galaxy Health Commercial |
$1,113.45
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,199.10
|
| Rate for Payer: Multiplan Commercial |
$770.85
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,113.45
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$1,113.45
|
| Rate for Payer: WellCare Medicare |
$942.15
|
|
|
SUPRANE
|
Facility
|
IP
|
$6.18
|
|
|
Service Code
|
NDC 10019064664
|
| Hospital Charge Code |
4409116
|
|
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
|
|
|
SUPRANE
|
Facility
|
OP
|
$6.18
|
|
|
Service Code
|
NDC 10019064664
|
| Hospital Charge Code |
4409116
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.10 |
| Max. Negotiated Rate |
$4.97 |
| Rate for Payer: Aetna of NY Commercial |
$4.33
|
| Rate for Payer: Aetna of NY Medicare |
$2.84
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$4.64
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$4.64
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$2.29
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$3.09
|
| Rate for Payer: Cash Price |
$4.64
|
| Rate for Payer: CDPHP Commercial |
$4.97
|
| Rate for Payer: CDPHP Medicare |
$2.29
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$4.94
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$4.94
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$4.94
|
| Rate for Payer: EmblemHealth Medicaid |
$4.94
|
| Rate for Payer: EmblemHealth Medicare |
$2.10
|
| Rate for Payer: EmblemHealth Select Care |
$4.45
|
| Rate for Payer: Fidelis Medicare |
$2.36
|
| Rate for Payer: Galaxy Health Commercial |
$4.02
|
| Rate for Payer: Hamaspik Choice Medicare |
$2.29
|
| Rate for Payer: Humana Medicare |
$2.29
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$4.33
|
| Rate for Payer: Local 1199SEIU Medicare |
$2.84
|
| Rate for Payer: MVP Health Care of NY Commercial |
$4.64
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$3.48
|
| Rate for Payer: MVP Health Care of NY Medicare |
$2.40
|
| Rate for Payer: United Healthcare Medicare |
$2.29
|
| Rate for Payer: WellCare Medicare |
$3.40
|
|
|
SUPRAPUBIC CATH SET 14 FR
|
Facility
|
OP
|
$363.00
|
|
|
Service Code
|
HCPCS C2627
|
| Hospital Charge Code |
4471056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$123.42 |
| Max. Negotiated Rate |
$292.22 |
| Rate for Payer: Aetna of NY Commercial |
$254.10
|
| Rate for Payer: Aetna of NY Medicare |
$166.98
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$272.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$272.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$134.31
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$181.50
|
| Rate for Payer: Cash Price |
$272.25
|
| Rate for Payer: CDPHP Commercial |
$292.22
|
| Rate for Payer: CDPHP Medicare |
$134.31
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$290.40
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$290.40
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$290.40
|
| Rate for Payer: EmblemHealth Medicaid |
$290.40
|
| Rate for Payer: EmblemHealth Medicare |
$123.42
|
| Rate for Payer: EmblemHealth Select Care |
$261.36
|
| Rate for Payer: Fidelis Medicare |
$138.34
|
| Rate for Payer: Galaxy Health Commercial |
$235.95
|
| Rate for Payer: Hamaspik Choice Medicare |
$134.31
|
| Rate for Payer: Humana Medicare |
$134.31
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$254.10
|
| Rate for Payer: Local 1199SEIU Medicare |
$166.98
|
| Rate for Payer: MVP Health Care of NY Commercial |
$272.25
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$204.37
|
| Rate for Payer: MVP Health Care of NY Medicare |
$141.03
|
| Rate for Payer: United Healthcare Medicare |
$134.31
|
| Rate for Payer: WellCare Medicare |
$199.65
|
|
|
SUPRAPUBIC CATH SET 14 FR
|
Facility
|
IP
|
$363.00
|
|
|
Service Code
|
HCPCS C2627
|
| Hospital Charge Code |
4471056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$235.95 |
| Max. Negotiated Rate |
$235.95 |
| Rate for Payer: Cash Price |
$272.25
|
| Rate for Payer: Galaxy Health Commercial |
$235.95
|
|
|
SURGIPRO 4/0 18IN BLUE FS-2 C-
|
Facility
|
IP
|
$34.00
|
|
| Hospital Charge Code |
4472083
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$22.10 |
| Max. Negotiated Rate |
$22.10 |
| Rate for Payer: Cash Price |
$25.50
|
| Rate for Payer: Galaxy Health Commercial |
$22.10
|
|
|
SURGIPRO 4/0 18IN BLUE FS-2 C-
|
Facility
|
OP
|
$34.00
|
|
| Hospital Charge Code |
4472083
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$11.56 |
| Max. Negotiated Rate |
$27.37 |
| Rate for Payer: Aetna of NY Commercial |
$23.80
|
| Rate for Payer: Aetna of NY Medicare |
$15.64
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$25.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$25.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$12.58
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$17.00
|
| Rate for Payer: Cash Price |
$25.50
|
| Rate for Payer: CDPHP Commercial |
$27.37
|
| Rate for Payer: CDPHP Medicare |
$12.58
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$27.20
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$27.20
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$27.20
|
| Rate for Payer: EmblemHealth Medicaid |
$27.20
|
| Rate for Payer: EmblemHealth Medicare |
$11.56
|
| Rate for Payer: EmblemHealth Select Care |
$24.48
|
| Rate for Payer: Fidelis Medicare |
$12.96
|
| Rate for Payer: Galaxy Health Commercial |
$22.10
|
| Rate for Payer: Hamaspik Choice Medicare |
$12.58
|
| Rate for Payer: Humana Medicare |
$12.58
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$23.80
|
| Rate for Payer: Local 1199SEIU Medicare |
$15.64
|
| Rate for Payer: MVP Health Care of NY Commercial |
$25.50
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$19.14
|
| Rate for Payer: MVP Health Care of NY Medicare |
$13.21
|
| Rate for Payer: United Healthcare Medicare |
$12.58
|
| Rate for Payer: WellCare Medicare |
$18.70
|
|
|
SURG PATH LVL 2
|
Facility
|
IP
|
$85.00
|
|
|
Service Code
|
HCPCS 88302 TC
|
| Hospital Charge Code |
4008302
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$55.25 |
| Max. Negotiated Rate |
$55.25 |
| Rate for Payer: Cash Price |
$63.75
|
| Rate for Payer: Galaxy Health Commercial |
$55.25
|
|
