|
TOXIN ASSAY TISSUE CULTURE
|
Facility
|
IP
|
$103.00
|
|
|
Service Code
|
HCPCS 87230
|
| Hospital Charge Code |
4301205
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$66.95 |
| Max. Negotiated Rate |
$66.95 |
| Rate for Payer: Cash Price |
$77.25
|
| Rate for Payer: Galaxy Health Commercial |
$66.95
|
|
|
TPN, > 1 LITER, <= 2 LITER PER DAY, ALL SUPPLIES/EQUIPMENT
|
Facility
|
IP
|
$449.00
|
|
| Hospital Charge Code |
1050101
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$246.95 |
| Max. Negotiated Rate |
$291.85 |
| Rate for Payer: Cash Price |
$336.75
|
| Rate for Payer: Galaxy Health Commercial |
$291.85
|
| Rate for Payer: WellCare Medicare |
$246.95
|
|
|
TPN, > 1 LITER, <= 2 LITER PER DAY, ALL SUPPLIES/EQUIPMENT
|
Facility
|
OP
|
$449.00
|
|
| Hospital Charge Code |
1050101
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$152.66 |
| Max. Negotiated Rate |
$361.44 |
| Rate for Payer: Aetna of NY Commercial |
$314.30
|
| Rate for Payer: Aetna of NY Medicare |
$206.54
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$336.75
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$336.75
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$166.13
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$224.50
|
| Rate for Payer: Cash Price |
$336.75
|
| Rate for Payer: CDPHP Commercial |
$361.44
|
| Rate for Payer: CDPHP Medicare |
$166.13
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$359.20
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$359.20
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$359.20
|
| Rate for Payer: EmblemHealth Medicaid |
$359.20
|
| Rate for Payer: EmblemHealth Medicare |
$152.66
|
| Rate for Payer: EmblemHealth Select Care |
$323.28
|
| Rate for Payer: Fidelis Medicare |
$171.11
|
| Rate for Payer: Galaxy Health Commercial |
$291.85
|
| Rate for Payer: Hamaspik Choice Medicare |
$166.13
|
| Rate for Payer: Humana Medicare |
$166.13
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$314.30
|
| Rate for Payer: Local 1199SEIU Medicare |
$206.54
|
| Rate for Payer: MVP Health Care of NY Commercial |
$336.75
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$252.79
|
| Rate for Payer: MVP Health Care of NY Medicare |
$174.44
|
| Rate for Payer: United Healthcare Medicare |
$166.13
|
| Rate for Payer: WellCare Medicare |
$246.95
|
|
|
TPN, > 2, <=3 LITERS PER DAY, ALL SUPPLIES/EQUIPMENT
|
Facility
|
IP
|
$479.00
|
|
| Hospital Charge Code |
1050102
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$263.45 |
| Max. Negotiated Rate |
$311.35 |
| Rate for Payer: Cash Price |
$359.25
|
| Rate for Payer: Galaxy Health Commercial |
$311.35
|
| Rate for Payer: WellCare Medicare |
$263.45
|
|
|
TPN, > 2, <=3 LITERS PER DAY, ALL SUPPLIES/EQUIPMENT
|
Facility
|
OP
|
$479.00
|
|
| Hospital Charge Code |
1050102
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$162.86 |
| Max. Negotiated Rate |
$385.60 |
| Rate for Payer: Aetna of NY Commercial |
$335.30
|
| Rate for Payer: Aetna of NY Medicare |
$220.34
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$359.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$359.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$177.23
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$239.50
|
| Rate for Payer: Cash Price |
$359.25
|
| Rate for Payer: CDPHP Commercial |
$385.60
|
| Rate for Payer: CDPHP Medicare |
$177.23
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$383.20
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$383.20
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$383.20
|
| Rate for Payer: EmblemHealth Medicaid |
$383.20
|
| Rate for Payer: EmblemHealth Medicare |
$162.86
|
| Rate for Payer: EmblemHealth Select Care |
$344.88
|
| Rate for Payer: Fidelis Medicare |
$182.55
|
| Rate for Payer: Galaxy Health Commercial |
$311.35
|
| Rate for Payer: Hamaspik Choice Medicare |
$177.23
|
| Rate for Payer: Humana Medicare |
$177.23
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$335.30
|
| Rate for Payer: Local 1199SEIU Medicare |
$220.34
|
| Rate for Payer: MVP Health Care of NY Commercial |
$359.25
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$269.68
|
| Rate for Payer: MVP Health Care of NY Medicare |
$186.09
|
| Rate for Payer: United Healthcare Medicare |
$177.23
|
| Rate for Payer: WellCare Medicare |
$263.45
|
|
|
TPN, > 3 LITERS PER DAY, ALL SUPPLIES/EQUIPMENT
|
Facility
|
OP
|
$513.00
|
|
| Hospital Charge Code |
1050103
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$174.42 |
| Max. Negotiated Rate |
$412.96 |
| Rate for Payer: Aetna of NY Commercial |
$359.10
|
| Rate for Payer: Aetna of NY Medicare |
$235.98
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$384.75
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$384.75
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$189.81
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$256.50
|
| Rate for Payer: Cash Price |
$384.75
|
| Rate for Payer: CDPHP Commercial |
$412.96
|
| Rate for Payer: CDPHP Medicare |
$189.81
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$410.40
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$410.40
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$410.40
|
| Rate for Payer: EmblemHealth Medicaid |
$410.40
|
| Rate for Payer: EmblemHealth Medicare |
$174.42
|
| Rate for Payer: EmblemHealth Select Care |
$369.36
|
| Rate for Payer: Fidelis Medicare |
$195.50
|
| Rate for Payer: Galaxy Health Commercial |
$333.45
|
| Rate for Payer: Hamaspik Choice Medicare |
$189.81
|
| Rate for Payer: Humana Medicare |
$189.81
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$359.10
|
| Rate for Payer: Local 1199SEIU Medicare |
$235.98
|
| Rate for Payer: MVP Health Care of NY Commercial |
$384.75
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$288.82
|
| Rate for Payer: MVP Health Care of NY Medicare |
$199.30
|
| Rate for Payer: United Healthcare Medicare |
$189.81
|
| Rate for Payer: WellCare Medicare |
$282.15
|
|
|
TPN, > 3 LITERS PER DAY, ALL SUPPLIES/EQUIPMENT
|
Facility
|
IP
|
$513.00
|
|
| Hospital Charge Code |
1050103
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$282.15 |
| Max. Negotiated Rate |
$333.45 |
| Rate for Payer: Cash Price |
$384.75
|
| Rate for Payer: Galaxy Health Commercial |
$333.45
|
| Rate for Payer: WellCare Medicare |
$282.15
|
|
|
TPN, UP TO ONE LITER PER DAY, ALL SUPPLIES/EQUIPMENT
|
Facility
|
OP
|
$413.00
|
|
| Hospital Charge Code |
1050100
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$140.42 |
| Max. Negotiated Rate |
$332.46 |
| Rate for Payer: Aetna of NY Commercial |
$289.10
|
| Rate for Payer: Aetna of NY Medicare |
$189.98
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$309.75
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$309.75
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$152.81
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$206.50
|
| Rate for Payer: Cash Price |
$309.75
|
| Rate for Payer: CDPHP Commercial |
$332.46
|
| Rate for Payer: CDPHP Medicare |
$152.81
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$330.40
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$330.40
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$330.40
|
| Rate for Payer: EmblemHealth Medicaid |
$330.40
|
| Rate for Payer: EmblemHealth Medicare |
$140.42
|
| Rate for Payer: EmblemHealth Select Care |
$297.36
|
| Rate for Payer: Fidelis Medicare |
$157.39
|
| Rate for Payer: Galaxy Health Commercial |
$268.45
|
| Rate for Payer: Hamaspik Choice Medicare |
$152.81
|
| Rate for Payer: Humana Medicare |
$152.81
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$289.10
|
| Rate for Payer: Local 1199SEIU Medicare |
$189.98
|
| Rate for Payer: MVP Health Care of NY Commercial |
$309.75
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$232.52
|
| Rate for Payer: MVP Health Care of NY Medicare |
$160.45
|
| Rate for Payer: United Healthcare Medicare |
$152.81
|
| Rate for Payer: WellCare Medicare |
$227.15
|
|
|
TPN, UP TO ONE LITER PER DAY, ALL SUPPLIES/EQUIPMENT
|
Facility
|
IP
|
$413.00
|
|
| Hospital Charge Code |
1050100
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$227.15 |
| Max. Negotiated Rate |
$268.45 |
| Rate for Payer: Cash Price |
$309.75
|
| Rate for Payer: Galaxy Health Commercial |
$268.45
|
| Rate for Payer: WellCare Medicare |
$227.15
|
|
|
TRADJENTA 5 MG TABLET 1 ea, 30 eaches
|
Facility
|
IP
|
$56.00
|
|
|
Service Code
|
NDC 00597014030
|
| Hospital Charge Code |
4401417
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$30.80 |
| Max. Negotiated Rate |
$36.40 |
| Rate for Payer: Cash Price |
$42.00
|
| Rate for Payer: Galaxy Health Commercial |
$36.40
|
| Rate for Payer: WellCare Medicare |
$30.80
|
|
|
TRADJENTA 5 MG TABLET 1 ea, 30 eaches
|
Facility
|
OP
|
$56.00
|
|
|
Service Code
|
NDC 00597014030
|
| Hospital Charge Code |
4401417
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.04 |
| Max. Negotiated Rate |
$45.08 |
| Rate for Payer: Aetna of NY Commercial |
$39.20
|
| Rate for Payer: Aetna of NY Medicare |
$25.76
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$42.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$42.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$20.72
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$28.00
|
| Rate for Payer: Cash Price |
$42.00
|
| Rate for Payer: CDPHP Commercial |
$45.08
|
| Rate for Payer: CDPHP Medicare |
$20.72
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$44.80
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$44.80
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$44.80
|
| Rate for Payer: EmblemHealth Medicaid |
$44.80
|
| Rate for Payer: EmblemHealth Medicare |
$19.04
|
| Rate for Payer: EmblemHealth Select Care |
$40.32
|
| Rate for Payer: Fidelis Medicare |
$21.34
|
| Rate for Payer: Galaxy Health Commercial |
$36.40
|
| Rate for Payer: Hamaspik Choice Medicare |
$20.72
|
| Rate for Payer: Humana Medicare |
$20.72
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$39.20
|
| Rate for Payer: Local 1199SEIU Medicare |
$25.76
|
| Rate for Payer: MVP Health Care of NY Commercial |
$42.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$31.53
|
| Rate for Payer: MVP Health Care of NY Medicare |
$21.76
|
| Rate for Payer: United Healthcare Medicare |
$20.72
|
| Rate for Payer: WellCare Medicare |
$30.80
|
|
|
TRAECHEOSTOMY SET 3.5MM
|
Facility
|
OP
|
$577.00
|
|
| Hospital Charge Code |
4471105
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$196.18 |
| Max. Negotiated Rate |
$464.48 |
| Rate for Payer: Aetna of NY Commercial |
$403.90
|
| Rate for Payer: Aetna of NY Medicare |
$265.42
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$432.75
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$432.75
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$213.49
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$288.50
|
| Rate for Payer: Cash Price |
$432.75
|
| Rate for Payer: CDPHP Commercial |
$464.48
|
| Rate for Payer: CDPHP Medicare |
$213.49
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$461.60
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$461.60
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$461.60
|
| Rate for Payer: EmblemHealth Medicaid |
$461.60
|
| Rate for Payer: EmblemHealth Medicare |
$196.18
|
| Rate for Payer: EmblemHealth Select Care |
$415.44
|
| Rate for Payer: Fidelis Medicare |
$219.89
|
| Rate for Payer: Galaxy Health Commercial |
$375.05
|
| Rate for Payer: Hamaspik Choice Medicare |
$213.49
|
| Rate for Payer: Humana Medicare |
$213.49
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$403.90
|
| Rate for Payer: Local 1199SEIU Medicare |
$265.42
|
| Rate for Payer: MVP Health Care of NY Commercial |
$432.75
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$324.85
|
| Rate for Payer: MVP Health Care of NY Medicare |
$224.16
|
| Rate for Payer: United Healthcare Medicare |
$213.49
|
| Rate for Payer: WellCare Medicare |
$317.35
|
|
|
TRAECHEOSTOMY SET 3.5MM
|
Facility
|
IP
|
$577.00
|
|
| Hospital Charge Code |
4471105
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$375.05 |
| Max. Negotiated Rate |
$375.05 |
| Rate for Payer: Cash Price |
$432.75
|
| Rate for Payer: Galaxy Health Commercial |
$375.05
|
|
|
TRAECHEOSTOMY SET 4.0MM
|
Facility
|
IP
|
$577.00
|
|
| Hospital Charge Code |
4471106
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$375.05 |
| Max. Negotiated Rate |
$375.05 |
| Rate for Payer: Cash Price |
$432.75
|
| Rate for Payer: Galaxy Health Commercial |
$375.05
|
|
|
TRAECHEOSTOMY SET 4.0MM
|
Facility
|
OP
|
$577.00
|
|
| Hospital Charge Code |
4471106
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$196.18 |
| Max. Negotiated Rate |
$464.48 |
| Rate for Payer: Aetna of NY Commercial |
$403.90
|
| Rate for Payer: Aetna of NY Medicare |
$265.42
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$432.75
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$432.75
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$213.49
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$288.50
|
| Rate for Payer: Cash Price |
$432.75
|
| Rate for Payer: CDPHP Commercial |
$464.48
|
| Rate for Payer: CDPHP Medicare |
$213.49
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$461.60
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$461.60
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$461.60
|
| Rate for Payer: EmblemHealth Medicaid |
$461.60
|
| Rate for Payer: EmblemHealth Medicare |
$196.18
|
| Rate for Payer: EmblemHealth Select Care |
$415.44
|
| Rate for Payer: Fidelis Medicare |
$219.89
|
| Rate for Payer: Galaxy Health Commercial |
$375.05
|
| Rate for Payer: Hamaspik Choice Medicare |
$213.49
|
| Rate for Payer: Humana Medicare |
$213.49
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$403.90
|
| Rate for Payer: Local 1199SEIU Medicare |
$265.42
|
| Rate for Payer: MVP Health Care of NY Commercial |
$432.75
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$324.85
|
| Rate for Payer: MVP Health Care of NY Medicare |
$224.16
|
| Rate for Payer: United Healthcare Medicare |
$213.49
|
| Rate for Payer: WellCare Medicare |
$317.35
|
|
|
TRAECHEOSTOMY SET 6MM
|
Facility
|
IP
|
$583.00
|
|
| Hospital Charge Code |
4471820
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$378.95 |
| Max. Negotiated Rate |
$378.95 |
| Rate for Payer: Cash Price |
$437.25
|
| Rate for Payer: Galaxy Health Commercial |
$378.95
|
|
|
TRAECHEOSTOMY SET 6MM
|
Facility
|
OP
|
$583.00
|
|
| Hospital Charge Code |
4471820
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$198.22 |
| Max. Negotiated Rate |
$469.32 |
| Rate for Payer: Aetna of NY Commercial |
$408.10
|
| Rate for Payer: Aetna of NY Medicare |
$268.18
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$437.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$437.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$215.71
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$291.50
|
| Rate for Payer: Cash Price |
$437.25
|
| Rate for Payer: CDPHP Commercial |
$469.32
|
| Rate for Payer: CDPHP Medicare |
$215.71
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$466.40
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$466.40
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$466.40
|
| Rate for Payer: EmblemHealth Medicaid |
$466.40
|
| Rate for Payer: EmblemHealth Medicare |
$198.22
|
| Rate for Payer: EmblemHealth Select Care |
$419.76
|
| Rate for Payer: Fidelis Medicare |
$222.18
|
| Rate for Payer: Galaxy Health Commercial |
$378.95
|
| Rate for Payer: Hamaspik Choice Medicare |
$215.71
|
| Rate for Payer: Humana Medicare |
$215.71
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$408.10
|
| Rate for Payer: Local 1199SEIU Medicare |
$268.18
|
| Rate for Payer: MVP Health Care of NY Commercial |
$437.25
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$328.23
|
| Rate for Payer: MVP Health Care of NY Medicare |
$226.50
|
| Rate for Payer: United Healthcare Medicare |
$215.71
|
| Rate for Payer: WellCare Medicare |
$320.65
|
|
|
TRAMADOL HCL 50MG TABS 100 EA
|
Facility
|
IP
|
$6.18
|
|
|
Service Code
|
NDC 65162062710
|
| Hospital Charge Code |
4400768
|
|
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
|
|
|
TRAMADOL HCL 50MG TABS 100 EA
|
Facility
|
OP
|
$6.18
|
|
|
Service Code
|
NDC 65162062710
|
| Hospital Charge Code |
4400768
|
|
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
|
|
|
TRANEXAMIC ACID 100 MG / ML INJECTION, 1
|
Facility
|
OP
|
$113.82
|
|
|
Service Code
|
NDC 39822100001
|
| Hospital Charge Code |
4409212
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$38.70 |
| Max. Negotiated Rate |
$91.63 |
| Rate for Payer: Aetna of NY Commercial |
$79.67
|
| Rate for Payer: Aetna of NY Medicare |
$52.36
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$85.36
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$85.36
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$42.11
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$56.91
|
| Rate for Payer: Cash Price |
$85.37
|
| Rate for Payer: CDPHP Commercial |
$91.63
|
| Rate for Payer: CDPHP Medicare |
$42.11
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$91.06
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$91.06
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$91.06
|
| Rate for Payer: EmblemHealth Medicaid |
$91.06
|
| Rate for Payer: EmblemHealth Medicare |
$38.70
|
| Rate for Payer: EmblemHealth Select Care |
$81.95
|
| Rate for Payer: Fidelis Medicare |
$43.38
|
| Rate for Payer: Galaxy Health Commercial |
$73.98
|
| Rate for Payer: Hamaspik Choice Medicare |
$42.11
|
| Rate for Payer: Humana Medicare |
$42.11
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$79.67
|
| Rate for Payer: Local 1199SEIU Medicare |
$52.36
|
| Rate for Payer: MVP Health Care of NY Commercial |
$85.36
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$64.08
|
| Rate for Payer: MVP Health Care of NY Medicare |
$44.22
|
| Rate for Payer: United Healthcare Medicare |
$42.11
|
| Rate for Payer: WellCare Medicare |
$62.60
|
|
|
TRANEXAMIC ACID 100 MG / ML INJECTION, 1
|
Facility
|
IP
|
$113.82
|
|
|
Service Code
|
NDC 39822100001
|
| Hospital Charge Code |
4409212
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$62.60 |
| Max. Negotiated Rate |
$73.98 |
| Rate for Payer: Cash Price |
$85.37
|
| Rate for Payer: Galaxy Health Commercial |
$73.98
|
| Rate for Payer: WellCare Medicare |
$62.60
|
|
|
TRANSCUTANEOUS PACING TEMPORAR
|
Facility
|
OP
|
$1,862.00
|
|
|
Service Code
|
HCPCS 92953
|
| Hospital Charge Code |
4600172
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$250.00 |
| Max. Negotiated Rate |
$1,498.91 |
| Rate for Payer: Aetna of NY Commercial |
$955.00
|
| Rate for Payer: Aetna of NY Medicare |
$856.52
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$950.93
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$1,189.18
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$688.94
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$931.00
|
| Rate for Payer: Cash Price |
$1,396.50
|
| Rate for Payer: Cash Price |
$1,396.50
|
| Rate for Payer: Cash Price |
$1,396.50
|
| Rate for Payer: Cash Price |
$1,396.50
|
| Rate for Payer: CDPHP Commercial |
$1,498.91
|
| Rate for Payer: CDPHP Medicare |
$688.94
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$1,182.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$1,489.60
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$1,489.60
|
| Rate for Payer: EmblemHealth Medicaid |
$1,489.60
|
| Rate for Payer: EmblemHealth Medicare |
$633.08
|
| Rate for Payer: EmblemHealth Select Care |
$1,064.00
|
| Rate for Payer: Fidelis Child Health Plus/Essential Plan/HARP/Medicaid |
$250.00
|
| Rate for Payer: Fidelis Medicare |
$709.61
|
| Rate for Payer: Galaxy Health Commercial |
$1,210.30
|
| Rate for Payer: Hamaspik Choice Medicare |
$688.94
|
| Rate for Payer: Humana Medicare |
$688.94
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$955.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$856.52
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,174.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$881.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$723.39
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$980.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$620.10
|
| Rate for Payer: United Healthcare Commercial |
$980.00
|
| Rate for Payer: United Healthcare Medicare |
$688.94
|
| Rate for Payer: WellCare Medicare |
$1,024.10
|
|
|
TRANSCUTANEOUS PACING TEMPORAR
|
Facility
|
IP
|
$1,862.00
|
|
|
Service Code
|
HCPCS 92953
|
| Hospital Charge Code |
4600172
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$1,210.30 |
| Max. Negotiated Rate |
$1,210.30 |
| Rate for Payer: Cash Price |
$1,396.50
|
| Rate for Payer: Galaxy Health Commercial |
$1,210.30
|
|
|
TRANSDISCAL INTRODUCER TDIB-17-150
|
Facility
|
OP
|
$406.00
|
|
| Hospital Charge Code |
4479254
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$138.04 |
| Max. Negotiated Rate |
$326.83 |
| Rate for Payer: Aetna of NY Commercial |
$284.20
|
| Rate for Payer: Aetna of NY Medicare |
$186.76
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$304.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$304.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$150.22
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$203.00
|
| Rate for Payer: Cash Price |
$304.50
|
| Rate for Payer: CDPHP Commercial |
$326.83
|
| Rate for Payer: CDPHP Medicare |
$150.22
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$324.80
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$324.80
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$324.80
|
| Rate for Payer: EmblemHealth Medicaid |
$324.80
|
| Rate for Payer: EmblemHealth Medicare |
$138.04
|
| Rate for Payer: EmblemHealth Select Care |
$292.32
|
| Rate for Payer: Fidelis Medicare |
$154.73
|
| Rate for Payer: Galaxy Health Commercial |
$263.90
|
| Rate for Payer: Hamaspik Choice Medicare |
$150.22
|
| Rate for Payer: Humana Medicare |
$150.22
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$284.20
|
| Rate for Payer: Local 1199SEIU Medicare |
$186.76
|
| Rate for Payer: MVP Health Care of NY Commercial |
$304.50
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$228.58
|
| Rate for Payer: MVP Health Care of NY Medicare |
$157.73
|
| Rate for Payer: United Healthcare Medicare |
$150.22
|
| Rate for Payer: WellCare Medicare |
$223.30
|
|
|
TRANSDISCAL INTRODUCER TDIB-17-150
|
Facility
|
IP
|
$406.00
|
|
| Hospital Charge Code |
4479254
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$263.90 |
| Max. Negotiated Rate |
$263.90 |
| Rate for Payer: Cash Price |
$304.50
|
| Rate for Payer: Galaxy Health Commercial |
$263.90
|
|
