|
TEST FOR ACETONE/KETONES
|
Facility
|
IP
|
$21.00
|
|
|
Service Code
|
HCPCS 82009
|
| Hospital Charge Code |
4302008
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.65 |
| Max. Negotiated Rate |
$13.65 |
| Rate for Payer: Cash Price |
$15.75
|
| Rate for Payer: Galaxy Health Commercial |
$13.65
|
|
|
TESTICULAR SCAN W/ FLOW
|
Facility
|
IP
|
$1,180.00
|
|
|
Service Code
|
HCPCS 78761
|
| Hospital Charge Code |
4210036
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$767.00 |
| Max. Negotiated Rate |
$767.00 |
| Rate for Payer: Cash Price |
$885.00
|
| Rate for Payer: Galaxy Health Commercial |
$767.00
|
|
|
TESTICULAR SCAN W/ FLOW
|
Facility
|
OP
|
$1,180.00
|
|
|
Service Code
|
HCPCS 78761
|
| Hospital Charge Code |
4210036
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$50.50 |
| Max. Negotiated Rate |
$1,500.00 |
| Rate for Payer: Aetna of NY Commercial |
$826.00
|
| Rate for Payer: Aetna of NY Medicare |
$542.80
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$885.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$885.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$436.60
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$590.00
|
| Rate for Payer: Cash Price |
$885.00
|
| Rate for Payer: Cash Price |
$885.00
|
| Rate for Payer: CDPHP Commercial |
$949.90
|
| Rate for Payer: CDPHP Medicare |
$436.60
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$826.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$944.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$944.00
|
| Rate for Payer: EmblemHealth Medicaid |
$944.00
|
| Rate for Payer: EmblemHealth Medicare |
$401.20
|
| Rate for Payer: EmblemHealth Select Care |
$767.00
|
| Rate for Payer: Fidelis Medicare |
$449.70
|
| Rate for Payer: Galaxy Health Commercial |
$767.00
|
| Rate for Payer: Hamaspik Choice Medicare |
$436.60
|
| Rate for Payer: Humana Medicare |
$436.60
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$826.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$542.80
|
| Rate for Payer: MVP Health Care of NY Commercial |
$885.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$664.34
|
| Rate for Payer: MVP Health Care of NY Medicare |
$458.43
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$1,500.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$50.50
|
| Rate for Payer: United Healthcare Commercial |
$1,500.00
|
| Rate for Payer: United Healthcare Medicare |
$436.60
|
| Rate for Payer: WellCare Medicare |
$649.00
|
|
|
TETRACAINE 0.5% 4 ML OPHTHALMIC DROPS
|
Facility
|
IP
|
$32.00
|
|
|
Service Code
|
NDC 00065074114
|
| Hospital Charge Code |
4409239
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.60 |
| Max. Negotiated Rate |
$20.80 |
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: Galaxy Health Commercial |
$20.80
|
| Rate for Payer: WellCare Medicare |
$17.60
|
|
|
TETRACAINE 0.5% 4 ML OPHTHALMIC DROPS
|
Facility
|
OP
|
$32.00
|
|
|
Service Code
|
NDC 00065074114
|
| Hospital Charge Code |
4409239
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.88 |
| Max. Negotiated Rate |
$25.76 |
| Rate for Payer: Aetna of NY Commercial |
$22.40
|
| Rate for Payer: Aetna of NY Medicare |
$14.72
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$24.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$24.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$11.84
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$16.00
|
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: CDPHP Commercial |
$25.76
|
| Rate for Payer: CDPHP Medicare |
$11.84
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$25.60
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$25.60
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$25.60
|
| Rate for Payer: EmblemHealth Medicaid |
$25.60
|
| Rate for Payer: EmblemHealth Medicare |
$10.88
|
| Rate for Payer: EmblemHealth Select Care |
$23.04
|
| Rate for Payer: Fidelis Medicare |
$12.20
|
| Rate for Payer: Galaxy Health Commercial |
$20.80
|
| Rate for Payer: Hamaspik Choice Medicare |
$11.84
|
| Rate for Payer: Humana Medicare |
$11.84
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$22.40
|
| Rate for Payer: Local 1199SEIU Medicare |
$14.72
|
| Rate for Payer: MVP Health Care of NY Commercial |
$24.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$18.02
|
| Rate for Payer: MVP Health Care of NY Medicare |
$12.43
|
| Rate for Payer: United Healthcare Medicare |
$11.84
|
| Rate for Payer: WellCare Medicare |
$17.60
|
|
|
TETRACAINE HCL 0.005 DROP 2 ML
|
Facility
|
IP
|
$33.99
|
|
|
Service Code
|
NDC 00065074112
|
| Hospital Charge Code |
4400749
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.69 |
| Max. Negotiated Rate |
$22.09 |
| Rate for Payer: Cash Price |
$25.49
|
| Rate for Payer: Galaxy Health Commercial |
$22.09
|
| Rate for Payer: WellCare Medicare |
$18.69
|
|
|
TETRACAINE HCL 0.005 DROP 2 ML
|
Facility
|
OP
|
$33.99
|
|
|
Service Code
|
NDC 00065074112
|
| Hospital Charge Code |
4400749
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.56 |
| Max. Negotiated Rate |
$27.36 |
| Rate for Payer: Aetna of NY Commercial |
$23.79
|
| Rate for Payer: Aetna of NY Medicare |
$15.64
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$25.49
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$25.49
|
| 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 |
$25.49
|
| Rate for Payer: CDPHP Commercial |
$27.36
|
| Rate for Payer: CDPHP Medicare |
$12.58
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$27.19
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$27.19
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$27.19
|
| Rate for Payer: EmblemHealth Medicaid |
$27.19
|
| Rate for Payer: EmblemHealth Medicare |
$11.56
|
| Rate for Payer: EmblemHealth Select Care |
$24.47
|
| Rate for Payer: Fidelis Medicare |
$12.95
|
| Rate for Payer: Galaxy Health Commercial |
$22.09
|
| Rate for Payer: Hamaspik Choice Medicare |
$12.58
|
| Rate for Payer: Humana Medicare |
$12.58
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$23.79
|
| Rate for Payer: Local 1199SEIU Medicare |
$15.64
|
| Rate for Payer: MVP Health Care of NY Commercial |
$25.49
|
| 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 |
$18.69
|
|
|
TETRACYC HCL/BIS SC/METRONID 125-140-125
|
Facility
|
OP
|
$17.00
|
|
| Hospital Charge Code |
4400670
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.78 |
| Max. Negotiated Rate |
$13.68 |
| Rate for Payer: Aetna of NY Commercial |
$11.90
|
| Rate for Payer: Aetna of NY Medicare |
$7.82
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$12.75
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$12.75
|
| 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: CDPHP Commercial |
$13.68
|
| 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 |
$13.60
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$13.60
|
| Rate for Payer: EmblemHealth Medicaid |
$13.60
|
| Rate for Payer: EmblemHealth Medicare |
$5.78
|
| Rate for Payer: EmblemHealth Select Care |
$12.24
|
| Rate for Payer: Fidelis Medicare |
$6.48
|
| Rate for Payer: Galaxy Health Commercial |
$11.05
|
| Rate for Payer: Hamaspik Choice Medicare |
$6.29
|
| Rate for Payer: Humana Medicare |
$6.29
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$11.90
|
| Rate for Payer: Local 1199SEIU Medicare |
$7.82
|
| Rate for Payer: MVP Health Care of NY Commercial |
$12.75
|
| 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: United Healthcare Medicare |
$6.29
|
| Rate for Payer: WellCare Medicare |
$9.35
|
|
|
TETRACYC HCL/BIS SC/METRONID 125-140-125
|
Facility
|
IP
|
$17.00
|
|
| Hospital Charge Code |
4400670
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.35 |
| Max. Negotiated Rate |
$11.05 |
| Rate for Payer: Cash Price |
$12.75
|
| Rate for Payer: Galaxy Health Commercial |
$11.05
|
| Rate for Payer: WellCare Medicare |
$9.35
|
|
|
THEOPHYLLINE
|
Facility
|
OP
|
$77.00
|
|
|
Service Code
|
HCPCS 80198
|
| Hospital Charge Code |
4300767
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.08 |
| Max. Negotiated Rate |
$61.98 |
| Rate for Payer: Aetna of NY Commercial |
$50.05
|
| Rate for Payer: Aetna of NY Medicare |
$35.42
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$57.75
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$57.75
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$28.49
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$38.50
|
| Rate for Payer: Cash Price |
$57.75
|
| Rate for Payer: Cash Price |
$57.75
|
| Rate for Payer: CDPHP Commercial |
$61.98
|
| Rate for Payer: CDPHP Medicare |
$28.49
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$46.20
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$61.60
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$61.60
|
| Rate for Payer: EmblemHealth Medicaid |
$61.60
|
| Rate for Payer: EmblemHealth Medicare |
$26.18
|
| Rate for Payer: EmblemHealth Select Care |
$46.20
|
| Rate for Payer: Fidelis Medicare |
$29.34
|
| Rate for Payer: Galaxy Health Commercial |
$50.05
|
| Rate for Payer: Hamaspik Choice Medicare |
$28.49
|
| Rate for Payer: Humana Medicare |
$28.49
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$50.05
|
| Rate for Payer: Local 1199SEIU Medicare |
$35.42
|
| Rate for Payer: MVP Health Care of NY Commercial |
$57.75
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$43.35
|
| Rate for Payer: MVP Health Care of NY Medicare |
$29.91
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$57.75
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$8.08
|
| Rate for Payer: United Healthcare Commercial |
$57.75
|
| Rate for Payer: United Healthcare Medicare |
$28.49
|
| Rate for Payer: WellCare Medicare |
$42.35
|
|
|
THEOPHYLLINE
|
Facility
|
IP
|
$77.00
|
|
|
Service Code
|
HCPCS 80198
|
| Hospital Charge Code |
4300767
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$50.05 |
| Max. Negotiated Rate |
$50.05 |
| Rate for Payer: Cash Price |
$57.75
|
| Rate for Payer: Galaxy Health Commercial |
$50.05
|
|
|
THEOPHYLLINE ER 300 MG TAB 300 mg, 100 eaches
|
Facility
|
IP
|
$13.00
|
|
|
Service Code
|
NDC 62332002531
|
| Hospital Charge Code |
4401318
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.15 |
| Max. Negotiated Rate |
$8.45 |
| Rate for Payer: Cash Price |
$9.75
|
| Rate for Payer: Galaxy Health Commercial |
$8.45
|
| Rate for Payer: WellCare Medicare |
$7.15
|
|
|
THEOPHYLLINE ER 300 MG TAB 300 mg, 100 eaches
|
Facility
|
OP
|
$13.00
|
|
|
Service Code
|
NDC 62332002531
|
| Hospital Charge Code |
4401318
|
|
Hospital Revenue Code
|
250
|
| 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
|
|
|
THEOPHYLLINE ER 400 MG TABLET 400 mg, 100 eaches
|
Facility
|
IP
|
$5.00
|
|
|
Service Code
|
NDC 42858070101
|
| Hospital Charge Code |
4401555
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.75 |
| Max. Negotiated Rate |
$3.25 |
| Rate for Payer: Cash Price |
$3.75
|
| Rate for Payer: Galaxy Health Commercial |
$3.25
|
| Rate for Payer: WellCare Medicare |
$2.75
|
|
|
THEOPHYLLINE ER 400 MG TABLET 400 mg, 100 eaches
|
Facility
|
OP
|
$5.00
|
|
|
Service Code
|
NDC 42858070101
|
| Hospital Charge Code |
4401555
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.70 |
| Max. Negotiated Rate |
$4.02 |
| Rate for Payer: Aetna of NY Commercial |
$3.50
|
| Rate for Payer: Aetna of NY Medicare |
$2.30
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$3.75
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$3.75
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$1.85
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$2.50
|
| Rate for Payer: Cash Price |
$3.75
|
| Rate for Payer: CDPHP Commercial |
$4.02
|
| Rate for Payer: CDPHP Medicare |
$1.85
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$4.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$4.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$4.00
|
| Rate for Payer: EmblemHealth Medicaid |
$4.00
|
| Rate for Payer: EmblemHealth Medicare |
$1.70
|
| Rate for Payer: EmblemHealth Select Care |
$3.60
|
| Rate for Payer: Fidelis Medicare |
$1.91
|
| Rate for Payer: Galaxy Health Commercial |
$3.25
|
| Rate for Payer: Hamaspik Choice Medicare |
$1.85
|
| Rate for Payer: Humana Medicare |
$1.85
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$3.50
|
| Rate for Payer: Local 1199SEIU Medicare |
$2.30
|
| Rate for Payer: MVP Health Care of NY Commercial |
$3.75
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$2.82
|
| Rate for Payer: MVP Health Care of NY Medicare |
$1.94
|
| Rate for Payer: United Healthcare Medicare |
$1.85
|
| Rate for Payer: WellCare Medicare |
$2.75
|
|
|
THERACATH EPIDURAL CATHETER EC-05000
|
Facility
|
OP
|
$100.00
|
|
| Hospital Charge Code |
4479083
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$34.00 |
| Max. Negotiated Rate |
$80.50 |
| Rate for Payer: Aetna of NY Commercial |
$70.00
|
| Rate for Payer: Aetna of NY Medicare |
$46.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$75.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$75.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$37.00
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$50.00
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: CDPHP Commercial |
$80.50
|
| Rate for Payer: CDPHP Medicare |
$37.00
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$80.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$80.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$80.00
|
| Rate for Payer: EmblemHealth Medicaid |
$80.00
|
| Rate for Payer: EmblemHealth Medicare |
$34.00
|
| Rate for Payer: EmblemHealth Select Care |
$72.00
|
| Rate for Payer: Fidelis Medicare |
$38.11
|
| Rate for Payer: Galaxy Health Commercial |
$65.00
|
| Rate for Payer: Hamaspik Choice Medicare |
$37.00
|
| Rate for Payer: Humana Medicare |
$37.00
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$70.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$46.00
|
| Rate for Payer: MVP Health Care of NY Commercial |
$75.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$56.30
|
| Rate for Payer: MVP Health Care of NY Medicare |
$38.85
|
| Rate for Payer: United Healthcare Medicare |
$37.00
|
| Rate for Payer: WellCare Medicare |
$55.00
|
|
|
THERACATH EPIDURAL CATHETER EC-05000
|
Facility
|
IP
|
$100.00
|
|
| Hospital Charge Code |
4479083
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$65.00 |
| Max. Negotiated Rate |
$65.00 |
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Galaxy Health Commercial |
$65.00
|
|
|
THERA-COOL INTRODUCER THI-17-75-5.5
|
Facility
|
IP
|
$204.00
|
|
| Hospital Charge Code |
4479244
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$132.60 |
| Max. Negotiated Rate |
$132.60 |
| Rate for Payer: Cash Price |
$153.00
|
| Rate for Payer: Galaxy Health Commercial |
$132.60
|
|
|
THERA-COOL INTRODUCER THI-17-75-5.5
|
Facility
|
OP
|
$204.00
|
|
| Hospital Charge Code |
4479244
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$69.36 |
| Max. Negotiated Rate |
$164.22 |
| Rate for Payer: Aetna of NY Commercial |
$142.80
|
| Rate for Payer: Aetna of NY Medicare |
$93.84
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$153.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$153.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$75.48
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$102.00
|
| Rate for Payer: Cash Price |
$153.00
|
| Rate for Payer: CDPHP Commercial |
$164.22
|
| Rate for Payer: CDPHP Medicare |
$75.48
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$163.20
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$163.20
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$163.20
|
| Rate for Payer: EmblemHealth Medicaid |
$163.20
|
| Rate for Payer: EmblemHealth Medicare |
$69.36
|
| Rate for Payer: EmblemHealth Select Care |
$146.88
|
| Rate for Payer: Fidelis Medicare |
$77.74
|
| Rate for Payer: Galaxy Health Commercial |
$132.60
|
| Rate for Payer: Hamaspik Choice Medicare |
$75.48
|
| Rate for Payer: Humana Medicare |
$75.48
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$142.80
|
| Rate for Payer: Local 1199SEIU Medicare |
$93.84
|
| Rate for Payer: MVP Health Care of NY Commercial |
$153.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$114.85
|
| Rate for Payer: MVP Health Care of NY Medicare |
$79.25
|
| Rate for Payer: United Healthcare Medicare |
$75.48
|
| Rate for Payer: WellCare Medicare |
$112.20
|
|
|
THERACOOL KIT-8451775 KIMBERLY CLARK
|
Facility
|
OP
|
$3,040.00
|
|
| Hospital Charge Code |
4479224
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$1,033.60 |
| Max. Negotiated Rate |
$2,447.20 |
| Rate for Payer: Aetna of NY Commercial |
$2,128.00
|
| Rate for Payer: Aetna of NY Medicare |
$1,398.40
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$2,280.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$2,280.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$1,124.80
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$1,520.00
|
| Rate for Payer: Cash Price |
$2,280.00
|
| Rate for Payer: CDPHP Commercial |
$2,447.20
|
| Rate for Payer: CDPHP Medicare |
$1,124.80
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$2,432.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$2,432.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$2,432.00
|
| Rate for Payer: EmblemHealth Medicaid |
$2,432.00
|
| Rate for Payer: EmblemHealth Medicare |
$1,033.60
|
| Rate for Payer: EmblemHealth Select Care |
$2,188.80
|
| Rate for Payer: Fidelis Medicare |
$1,158.54
|
| Rate for Payer: Galaxy Health Commercial |
$1,976.00
|
| Rate for Payer: Hamaspik Choice Medicare |
$1,124.80
|
| Rate for Payer: Humana Medicare |
$1,124.80
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$2,128.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$1,398.40
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,280.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$1,711.52
|
| Rate for Payer: MVP Health Care of NY Medicare |
$1,181.04
|
| Rate for Payer: United Healthcare Medicare |
$1,124.80
|
| Rate for Payer: WellCare Medicare |
$1,672.00
|
|
|
THERACOOL KIT-8451775 KIMBERLY CLARK
|
Facility
|
IP
|
$3,040.00
|
|
| Hospital Charge Code |
4479224
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$1,976.00 |
| Max. Negotiated Rate |
$1,976.00 |
| Rate for Payer: Cash Price |
$2,280.00
|
| Rate for Payer: Galaxy Health Commercial |
$1,976.00
|
|
|
THERACOOL PROBE KIT, SINGLE-USE
|
Facility
|
IP
|
$1,023.00
|
|
| Hospital Charge Code |
4479202
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$664.95 |
| Max. Negotiated Rate |
$664.95 |
| Rate for Payer: Cash Price |
$767.25
|
| Rate for Payer: Galaxy Health Commercial |
$664.95
|
|
|
THERACOOL PROBE KIT, SINGLE-USE
|
Facility
|
OP
|
$1,023.00
|
|
| Hospital Charge Code |
4479202
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$347.82 |
| Max. Negotiated Rate |
$823.52 |
| Rate for Payer: Aetna of NY Commercial |
$716.10
|
| Rate for Payer: Aetna of NY Medicare |
$470.58
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$767.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$767.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$378.51
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$511.50
|
| Rate for Payer: Cash Price |
$767.25
|
| Rate for Payer: CDPHP Commercial |
$823.52
|
| Rate for Payer: CDPHP Medicare |
$378.51
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$818.40
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$818.40
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$818.40
|
| Rate for Payer: EmblemHealth Medicaid |
$818.40
|
| Rate for Payer: EmblemHealth Medicare |
$347.82
|
| Rate for Payer: EmblemHealth Select Care |
$736.56
|
| Rate for Payer: Fidelis Medicare |
$389.87
|
| Rate for Payer: Galaxy Health Commercial |
$664.95
|
| Rate for Payer: Hamaspik Choice Medicare |
$378.51
|
| Rate for Payer: Humana Medicare |
$378.51
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$716.10
|
| Rate for Payer: Local 1199SEIU Medicare |
$470.58
|
| Rate for Payer: MVP Health Care of NY Commercial |
$767.25
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$575.95
|
| Rate for Payer: MVP Health Care of NY Medicare |
$397.44
|
| Rate for Payer: United Healthcare Medicare |
$378.51
|
| Rate for Payer: WellCare Medicare |
$562.65
|
|
|
THERAPEUTIC ACTIVITY 15 MIN
|
Facility
|
IP
|
$136.00
|
|
|
Service Code
|
HCPCS 97530 GN
|
| Hospital Charge Code |
4670074
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$88.40 |
| Max. Negotiated Rate |
$88.40 |
| Rate for Payer: Cash Price |
$102.00
|
| Rate for Payer: Galaxy Health Commercial |
$88.40
|
|
|
THERAPEUTIC ACTIVITY 15 MIN
|
Facility
|
OP
|
$136.00
|
|
|
Service Code
|
HCPCS 97530 GN
|
| Hospital Charge Code |
4670074
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$46.24 |
| Max. Negotiated Rate |
$179.00 |
| Rate for Payer: Aetna of NY Commercial |
$112.00
|
| Rate for Payer: Aetna of NY Medicare |
$62.56
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$102.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$102.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$50.32
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$108.00
|
| Rate for Payer: Cash Price |
$102.00
|
| Rate for Payer: Cash Price |
$102.00
|
| Rate for Payer: Cash Price |
$102.00
|
| Rate for Payer: CDPHP Commercial |
$109.48
|
| Rate for Payer: CDPHP Medicare |
$50.32
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$108.80
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$108.80
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$108.80
|
| Rate for Payer: EmblemHealth Medicaid |
$108.80
|
| Rate for Payer: EmblemHealth Medicare |
$46.24
|
| Rate for Payer: EmblemHealth Select Care |
$97.92
|
| Rate for Payer: Fidelis Medicare |
$51.83
|
| Rate for Payer: Galaxy Health Commercial |
$88.40
|
| Rate for Payer: Hamaspik Choice Medicare |
$50.32
|
| Rate for Payer: Humana Medicare |
$50.32
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$112.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$62.56
|
| 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 |
$52.84
|
| 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 |
$50.32
|
| Rate for Payer: WellCare Medicare |
$74.80
|
|
