|
SINUS RELIEF 1% NASAL SPRAY 1 ea, 30 mL
|
Facility
|
IP
|
$12.00
|
|
|
Service Code
|
NDC 70000013201
|
| Hospital Charge Code |
4401399
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.60 |
| Max. Negotiated Rate |
$7.80 |
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Galaxy Health Commercial |
$7.80
|
| Rate for Payer: WellCare Medicare |
$6.60
|
|
|
SINUS RELIEF 1% NASAL SPRAY 1 ea, 30 mL
|
Facility
|
OP
|
$12.00
|
|
|
Service Code
|
NDC 70000013201
|
| Hospital Charge Code |
4401399
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.80 |
| Max. Negotiated Rate |
$9.60 |
| Rate for Payer: Aetna of NY Commercial |
$8.40
|
| Rate for Payer: Aetna of NY Medicare |
$5.52
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$4.80
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: CDPHP Medicare |
$4.44
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$9.60
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$9.60
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$9.60
|
| Rate for Payer: EmblemHealth Medicaid |
$9.60
|
| Rate for Payer: EmblemHealth Medicare |
$4.08
|
| Rate for Payer: EmblemHealth Select Care |
$8.64
|
| Rate for Payer: Fidelis Medicare |
$4.80
|
| Rate for Payer: Galaxy Health Commercial |
$7.80
|
| Rate for Payer: Hamaspik Choice Medicare |
$4.80
|
| Rate for Payer: Humana Medicare |
$4.80
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$8.40
|
| Rate for Payer: Local 1199SEIU Medicare |
$5.52
|
| Rate for Payer: MVP Health Care of NY Commercial |
$9.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$6.76
|
| Rate for Payer: MVP Health Care of NY Medicare |
$5.04
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$1.80
|
| Rate for Payer: United Healthcare Medicare |
$4.80
|
| Rate for Payer: WellCare Medicare |
$6.60
|
|
|
SIZE 15/2 BALLOONS
|
Facility
|
OP
|
$1,927.13
|
|
| Hospital Charge Code |
4471961
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$289.07 |
| Max. Negotiated Rate |
$1,541.70 |
| Rate for Payer: Aetna of NY Commercial |
$1,348.99
|
| Rate for Payer: Aetna of NY Medicare |
$886.48
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$770.85
|
| Rate for Payer: Cash Price |
$1,445.35
|
| Rate for Payer: CDPHP Medicare |
$713.04
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$1,541.70
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$1,541.70
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$1,541.70
|
| Rate for Payer: EmblemHealth Medicaid |
$1,541.70
|
| Rate for Payer: EmblemHealth Medicare |
$655.22
|
| Rate for Payer: EmblemHealth Select Care |
$1,387.53
|
| Rate for Payer: Fidelis Medicare |
$770.85
|
| Rate for Payer: Galaxy Health Commercial |
$1,252.63
|
| Rate for Payer: Hamaspik Choice Medicare |
$770.85
|
| Rate for Payer: Humana Medicare |
$770.85
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,348.99
|
| Rate for Payer: Local 1199SEIU Medicare |
$886.48
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,445.35
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$1,084.97
|
| Rate for Payer: MVP Health Care of NY Medicare |
$809.39
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$289.07
|
| Rate for Payer: United Healthcare Medicare |
$770.85
|
| Rate for Payer: WellCare Medicare |
$1,059.92
|
|
|
SIZE 15/2 BALLOONS
|
Facility
|
IP
|
$1,927.13
|
|
| Hospital Charge Code |
4471961
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,252.63 |
| Max. Negotiated Rate |
$1,252.63 |
| Rate for Payer: Cash Price |
$1,445.35
|
| Rate for Payer: Galaxy Health Commercial |
$1,252.63
|
|
|
SIZE 2 BONE BIOPSY DEVICE
|
Facility
|
OP
|
$545.90
|
|
| Hospital Charge Code |
4471869
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$81.89 |
| Max. Negotiated Rate |
$436.72 |
| Rate for Payer: Aetna of NY Commercial |
$382.13
|
| Rate for Payer: Aetna of NY Medicare |
$251.11
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$218.36
|
| Rate for Payer: Cash Price |
$409.42
|
| Rate for Payer: CDPHP Medicare |
$201.98
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$272.95
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$436.72
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$436.72
|
| Rate for Payer: EmblemHealth Medicaid |
$436.72
|
| Rate for Payer: EmblemHealth Medicare |
$185.61
|
| Rate for Payer: EmblemHealth Select Care |
$272.95
|
| Rate for Payer: Fidelis Medicare |
$218.36
|
| Rate for Payer: Galaxy Health Commercial |
$354.83
|
| Rate for Payer: Hamaspik Choice Medicare |
$218.36
|
| Rate for Payer: Humana Medicare |
$218.36
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$382.13
|
| Rate for Payer: Local 1199SEIU Medicare |
$251.11
|
| Rate for Payer: MVP Health Care of NY Commercial |
$354.83
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$354.83
|
| Rate for Payer: MVP Health Care of NY Medicare |
$229.28
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$81.89
|
| Rate for Payer: United Healthcare Medicare |
$218.36
|
| Rate for Payer: WellCare Medicare |
$300.25
|
|
|
SIZE 2 BONE BIOPSY DEVICE
|
Facility
|
IP
|
$545.90
|
|
| Hospital Charge Code |
4471869
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$245.66 |
| Max. Negotiated Rate |
$382.13 |
| Rate for Payer: Aetna of NY Commercial |
$382.13
|
| Rate for Payer: Cash Price |
$409.42
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$272.95
|
| Rate for Payer: EmblemHealth Select Care |
$272.95
|
| Rate for Payer: Galaxy Health Commercial |
$354.83
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$382.13
|
| Rate for Payer: Multiplan Commercial |
$245.66
|
| Rate for Payer: MVP Health Care of NY Commercial |
$354.83
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$354.83
|
| Rate for Payer: WellCare Medicare |
$300.25
|
|
|
SIZE 3 BIOPSY
|
Facility
|
OP
|
$22.66
|
|
| Hospital Charge Code |
4471868
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$3.40 |
| Max. Negotiated Rate |
$18.13 |
| Rate for Payer: Aetna of NY Commercial |
$15.86
|
| Rate for Payer: Aetna of NY Medicare |
$10.42
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$9.06
|
| Rate for Payer: Cash Price |
$17.00
|
| Rate for Payer: CDPHP Medicare |
$8.38
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$18.13
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$18.13
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$18.13
|
| Rate for Payer: EmblemHealth Medicaid |
$18.13
|
| Rate for Payer: EmblemHealth Medicare |
$7.70
|
| Rate for Payer: EmblemHealth Select Care |
$16.32
|
| Rate for Payer: Fidelis Medicare |
$9.06
|
| Rate for Payer: Galaxy Health Commercial |
$14.73
|
| Rate for Payer: Hamaspik Choice Medicare |
$9.06
|
| Rate for Payer: Humana Medicare |
$9.06
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$15.86
|
| Rate for Payer: Local 1199SEIU Medicare |
$10.42
|
| Rate for Payer: MVP Health Care of NY Commercial |
$17.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$12.76
|
| Rate for Payer: MVP Health Care of NY Medicare |
$9.52
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$3.40
|
| Rate for Payer: United Healthcare Medicare |
$9.06
|
| Rate for Payer: WellCare Medicare |
$12.46
|
|
|
SIZE 3 BIOPSY
|
Facility
|
IP
|
$22.66
|
|
| Hospital Charge Code |
4471868
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$14.73 |
| Max. Negotiated Rate |
$14.73 |
| Rate for Payer: Cash Price |
$17.00
|
| Rate for Payer: Galaxy Health Commercial |
$14.73
|
|
|
SIZE 4 SHILEY
|
Facility
|
OP
|
$352.26
|
|
| Hospital Charge Code |
4479142
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$52.84 |
| Max. Negotiated Rate |
$281.81 |
| Rate for Payer: Aetna of NY Commercial |
$246.58
|
| Rate for Payer: Aetna of NY Medicare |
$162.04
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$140.90
|
| Rate for Payer: Cash Price |
$264.20
|
| Rate for Payer: CDPHP Medicare |
$130.34
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$281.81
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$281.81
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$281.81
|
| Rate for Payer: EmblemHealth Medicaid |
$281.81
|
| Rate for Payer: EmblemHealth Medicare |
$119.77
|
| Rate for Payer: EmblemHealth Select Care |
$253.63
|
| Rate for Payer: Fidelis Medicare |
$140.90
|
| Rate for Payer: Galaxy Health Commercial |
$228.97
|
| Rate for Payer: Hamaspik Choice Medicare |
$140.90
|
| Rate for Payer: Humana Medicare |
$140.90
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$246.58
|
| Rate for Payer: Local 1199SEIU Medicare |
$162.04
|
| Rate for Payer: MVP Health Care of NY Commercial |
$264.19
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$198.32
|
| Rate for Payer: MVP Health Care of NY Medicare |
$147.95
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$52.84
|
| Rate for Payer: United Healthcare Medicare |
$140.90
|
| Rate for Payer: WellCare Medicare |
$193.74
|
|
|
SIZE 4 SHILEY
|
Facility
|
IP
|
$352.26
|
|
| Hospital Charge Code |
4479142
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$228.97 |
| Max. Negotiated Rate |
$228.97 |
| Rate for Payer: Cash Price |
$264.20
|
| Rate for Payer: Galaxy Health Commercial |
$228.97
|
|
|
SIZE 6 SHILEY
|
Facility
|
IP
|
$352.26
|
|
| Hospital Charge Code |
4479143
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$228.97 |
| Max. Negotiated Rate |
$228.97 |
| Rate for Payer: Cash Price |
$264.20
|
| Rate for Payer: Galaxy Health Commercial |
$228.97
|
|
|
SIZE 6 SHILEY
|
Facility
|
OP
|
$352.26
|
|
| Hospital Charge Code |
4479143
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$52.84 |
| Max. Negotiated Rate |
$281.81 |
| Rate for Payer: Aetna of NY Commercial |
$246.58
|
| Rate for Payer: Aetna of NY Medicare |
$162.04
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$140.90
|
| Rate for Payer: Cash Price |
$264.20
|
| Rate for Payer: CDPHP Medicare |
$130.34
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$281.81
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$281.81
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$281.81
|
| Rate for Payer: EmblemHealth Medicaid |
$281.81
|
| Rate for Payer: EmblemHealth Medicare |
$119.77
|
| Rate for Payer: EmblemHealth Select Care |
$253.63
|
| Rate for Payer: Fidelis Medicare |
$140.90
|
| Rate for Payer: Galaxy Health Commercial |
$228.97
|
| Rate for Payer: Hamaspik Choice Medicare |
$140.90
|
| Rate for Payer: Humana Medicare |
$140.90
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$246.58
|
| Rate for Payer: Local 1199SEIU Medicare |
$162.04
|
| Rate for Payer: MVP Health Care of NY Commercial |
$264.19
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$198.32
|
| Rate for Payer: MVP Health Care of NY Medicare |
$147.95
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$52.84
|
| Rate for Payer: United Healthcare Medicare |
$140.90
|
| Rate for Payer: WellCare Medicare |
$193.74
|
|
|
SKIN BARRIER (COLOSTOMY SUPPLY)
|
Facility
|
IP
|
$36.05
|
|
| Hospital Charge Code |
4479195
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$23.43 |
| Max. Negotiated Rate |
$23.43 |
| Rate for Payer: Cash Price |
$27.04
|
| Rate for Payer: Galaxy Health Commercial |
$23.43
|
|
|
SKIN BARRIER (COLOSTOMY SUPPLY)
|
Facility
|
OP
|
$36.05
|
|
| Hospital Charge Code |
4479195
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$5.41 |
| Max. Negotiated Rate |
$28.84 |
| Rate for Payer: Aetna of NY Commercial |
$25.23
|
| Rate for Payer: Aetna of NY Medicare |
$16.58
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$14.42
|
| Rate for Payer: Cash Price |
$27.04
|
| Rate for Payer: CDPHP Medicare |
$13.34
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$28.84
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$28.84
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$28.84
|
| Rate for Payer: EmblemHealth Medicaid |
$28.84
|
| Rate for Payer: EmblemHealth Medicare |
$12.26
|
| Rate for Payer: EmblemHealth Select Care |
$25.96
|
| Rate for Payer: Fidelis Medicare |
$14.42
|
| Rate for Payer: Galaxy Health Commercial |
$23.43
|
| Rate for Payer: Hamaspik Choice Medicare |
$14.42
|
| Rate for Payer: Humana Medicare |
$14.42
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$25.23
|
| Rate for Payer: Local 1199SEIU Medicare |
$16.58
|
| Rate for Payer: MVP Health Care of NY Commercial |
$27.04
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$20.30
|
| Rate for Payer: MVP Health Care of NY Medicare |
$15.14
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$5.41
|
| Rate for Payer: United Healthcare Medicare |
$14.42
|
| Rate for Payer: WellCare Medicare |
$19.83
|
|
|
SKIN SUB GRAFT FACE/NK/HF/G
|
Facility
|
OP
|
$2,265.00
|
|
|
Service Code
|
HCPCS 15275
|
| Hospital Charge Code |
4852007
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$339.75 |
| Max. Negotiated Rate |
$1,812.00 |
| Rate for Payer: Aetna of NY Commercial |
$1,585.50
|
| Rate for Payer: Aetna of NY Medicare |
$1,041.90
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$906.00
|
| Rate for Payer: Cash Price |
$1,698.75
|
| Rate for Payer: CDPHP Medicare |
$838.05
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$1,812.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$1,812.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$1,812.00
|
| Rate for Payer: EmblemHealth Medicaid |
$1,812.00
|
| Rate for Payer: EmblemHealth Medicare |
$770.10
|
| Rate for Payer: EmblemHealth Select Care |
$1,630.80
|
| Rate for Payer: Fidelis Medicare |
$906.00
|
| Rate for Payer: Galaxy Health Commercial |
$1,472.25
|
| Rate for Payer: Hamaspik Choice Medicare |
$906.00
|
| Rate for Payer: Humana Medicare |
$906.00
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,585.50
|
| Rate for Payer: Local 1199SEIU Medicare |
$1,041.90
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,698.75
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$1,275.19
|
| Rate for Payer: MVP Health Care of NY Medicare |
$951.30
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$339.75
|
| Rate for Payer: United Healthcare Medicare |
$906.00
|
| Rate for Payer: WellCare Medicare |
$1,245.75
|
|
|
SKIN SUB GRAFT FACE/NK/HF/G
|
Facility
|
IP
|
$2,265.00
|
|
|
Service Code
|
HCPCS 15275
|
| Hospital Charge Code |
4852007
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,472.25 |
| Max. Negotiated Rate |
$1,472.25 |
| Rate for Payer: Cash Price |
$1,698.75
|
| Rate for Payer: Galaxy Health Commercial |
$1,472.25
|
|
|
SKIN SUB GRAFT TRNK/ARM/LEG
|
Facility
|
IP
|
$2,265.00
|
|
|
Service Code
|
HCPCS 15271
|
| Hospital Charge Code |
4850303
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,472.25 |
| Max. Negotiated Rate |
$1,472.25 |
| Rate for Payer: Cash Price |
$1,698.75
|
| Rate for Payer: Galaxy Health Commercial |
$1,472.25
|
|
|
SKIN SUB GRAFT TRNK/ARM/LEG
|
Facility
|
OP
|
$2,265.00
|
|
|
Service Code
|
HCPCS 15271
|
| Hospital Charge Code |
4850303
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$339.75 |
| Max. Negotiated Rate |
$1,812.00 |
| Rate for Payer: Aetna of NY Commercial |
$1,585.50
|
| Rate for Payer: Aetna of NY Medicare |
$1,041.90
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$906.00
|
| Rate for Payer: Cash Price |
$1,698.75
|
| Rate for Payer: CDPHP Medicare |
$838.05
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$1,812.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$1,812.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$1,812.00
|
| Rate for Payer: EmblemHealth Medicaid |
$1,812.00
|
| Rate for Payer: EmblemHealth Medicare |
$770.10
|
| Rate for Payer: EmblemHealth Select Care |
$1,630.80
|
| Rate for Payer: Fidelis Medicare |
$906.00
|
| Rate for Payer: Galaxy Health Commercial |
$1,472.25
|
| Rate for Payer: Hamaspik Choice Medicare |
$906.00
|
| Rate for Payer: Humana Medicare |
$906.00
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,585.50
|
| Rate for Payer: Local 1199SEIU Medicare |
$1,041.90
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,698.75
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$1,275.19
|
| Rate for Payer: MVP Health Care of NY Medicare |
$951.30
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$339.75
|
| Rate for Payer: United Healthcare Medicare |
$906.00
|
| Rate for Payer: WellCare Medicare |
$1,245.75
|
|
|
SKIN TEST TUBERCULOSIS INTRADERMAL
|
Facility
|
IP
|
$89.00
|
|
|
Service Code
|
HCPCS 86580
|
| Hospital Charge Code |
4300013
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$57.85 |
| Max. Negotiated Rate |
$57.85 |
| Rate for Payer: Cash Price |
$66.75
|
| Rate for Payer: Galaxy Health Commercial |
$57.85
|
|
|
SKIN TEST TUBERCULOSIS INTRADERMAL
|
Facility
|
OP
|
$89.00
|
|
|
Service Code
|
HCPCS 86580
|
| Hospital Charge Code |
4300013
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$4.95 |
| Max. Negotiated Rate |
$66.75 |
| Rate for Payer: Aetna of NY Commercial |
$57.85
|
| Rate for Payer: Aetna of NY Medicare |
$40.94
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$35.60
|
| Rate for Payer: Cash Price |
$66.75
|
| Rate for Payer: Cash Price |
$66.75
|
| Rate for Payer: CDPHP Medicare |
$32.93
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$53.40
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$6.06
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$5.05
|
| Rate for Payer: EmblemHealth Medicaid |
$5.05
|
| Rate for Payer: EmblemHealth Medicare |
$30.26
|
| Rate for Payer: EmblemHealth Select Care |
$53.40
|
| Rate for Payer: Fidelis Medicare |
$35.60
|
| Rate for Payer: Galaxy Health Commercial |
$57.85
|
| Rate for Payer: Galaxy Health Workers Comp |
$4.95
|
| Rate for Payer: Hamaspik Choice Medicaid |
$5.05
|
| Rate for Payer: Hamaspik Choice Medicare |
$35.60
|
| Rate for Payer: Humana Medicare |
$35.60
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$57.85
|
| Rate for Payer: Local 1199SEIU Medicare |
$40.94
|
| Rate for Payer: MVP Health Care of NY Child Health Plus/Family Health Plus/HARP/Medicaid |
$5.30
|
| Rate for Payer: MVP Health Care of NY Commercial |
$66.75
|
| Rate for Payer: MVP Health Care of NY Essential Plan 1&2 |
$10.86
|
| Rate for Payer: MVP Health Care of NY Essential Plan 3&4 |
$10.86
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$50.11
|
| Rate for Payer: MVP Health Care of NY Medicare |
$37.38
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$66.75
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$13.35
|
| Rate for Payer: United Healthcare Commercial |
$66.75
|
| Rate for Payer: United Healthcare Medicare |
$35.60
|
| Rate for Payer: WellCare Child Health Plus/Family Health Plus/Medicaid |
$5.30
|
| Rate for Payer: WellCare Medicare |
$48.95
|
|
|
SKYRIZI 600 MG/10 ML VIAL 600 mg, 10 mL
|
Facility
|
OP
|
$55.00
|
|
|
Service Code
|
HCPCS J2327
|
| Hospital Charge Code |
4401545
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.25 |
| Max. Negotiated Rate |
$44.00 |
| Rate for Payer: Aetna of NY Medicare |
$25.30
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$22.00
|
| Rate for Payer: Cash Price |
$41.25
|
| Rate for Payer: Cash Price |
$41.25
|
| Rate for Payer: CDPHP Medicare |
$20.35
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$14.60
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$44.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$44.00
|
| Rate for Payer: EmblemHealth Medicaid |
$44.00
|
| Rate for Payer: EmblemHealth Medicare |
$18.70
|
| Rate for Payer: EmblemHealth Select Care |
$14.60
|
| Rate for Payer: Fidelis Medicare |
$22.00
|
| Rate for Payer: Galaxy Health Commercial |
$35.75
|
| Rate for Payer: Hamaspik Choice Medicare |
$22.00
|
| Rate for Payer: Humana Medicare |
$22.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$25.30
|
| Rate for Payer: MVP Health Care of NY Commercial |
$41.25
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$30.96
|
| Rate for Payer: MVP Health Care of NY Medicare |
$23.10
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$25.61
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$8.25
|
| Rate for Payer: United Healthcare Commercial |
$25.61
|
| Rate for Payer: United Healthcare Medicare |
$22.00
|
| Rate for Payer: WellCare Medicare |
$30.25
|
|
|
SKYRIZI 600 MG/10 ML VIAL 600 mg, 10 mL
|
Facility
|
IP
|
$55.00
|
|
|
Service Code
|
HCPCS J2327
|
| Hospital Charge Code |
4401545
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.60 |
| Max. Negotiated Rate |
$35.75 |
| Rate for Payer: Aetna of NY Commercial |
$30.25
|
| Rate for Payer: Cash Price |
$41.25
|
| Rate for Payer: Cash Price |
$41.25
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$14.60
|
| Rate for Payer: EmblemHealth Select Care |
$14.60
|
| Rate for Payer: Galaxy Health Commercial |
$35.75
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$30.25
|
| Rate for Payer: WellCare Medicare |
$30.25
|
|
|
SLCTV WND DEBRIDEM 20 CM OR <
|
Facility
|
OP
|
$156.00
|
|
|
Service Code
|
HCPCS 97598
|
| Hospital Charge Code |
4650035
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$23.40 |
| Max. Negotiated Rate |
$161.00 |
| Rate for Payer: Aetna of NY Commercial |
$109.20
|
| Rate for Payer: Aetna of NY Medicare |
$71.76
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$62.40
|
| Rate for Payer: Cash Price |
$117.00
|
| Rate for Payer: Cash Price |
$117.00
|
| Rate for Payer: CDPHP Medicare |
$57.72
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$124.80
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$124.80
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$124.80
|
| Rate for Payer: EmblemHealth Medicaid |
$124.80
|
| Rate for Payer: EmblemHealth Medicare |
$53.04
|
| Rate for Payer: EmblemHealth Select Care |
$112.32
|
| Rate for Payer: Fidelis Medicare |
$62.40
|
| Rate for Payer: Galaxy Health Commercial |
$101.40
|
| Rate for Payer: Hamaspik Choice Medicare |
$62.40
|
| Rate for Payer: Humana Medicare |
$62.40
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$109.20
|
| Rate for Payer: Local 1199SEIU Medicare |
$71.76
|
| Rate for Payer: MVP Health Care of NY Commercial |
$117.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$87.83
|
| Rate for Payer: MVP Health Care of NY Medicare |
$65.52
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$161.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$23.40
|
| Rate for Payer: United Healthcare Commercial |
$161.00
|
| Rate for Payer: United Healthcare Medicare |
$62.40
|
| Rate for Payer: WellCare Medicare |
$85.80
|
|
|
SLCTV WND DEBRIDEM 20 CM OR <
|
Facility
|
OP
|
$615.00
|
|
|
Service Code
|
HCPCS 97597
|
| Hospital Charge Code |
4856724
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$92.25 |
| Max. Negotiated Rate |
$492.00 |
| Rate for Payer: Aetna of NY Commercial |
$430.50
|
| Rate for Payer: Aetna of NY Medicare |
$282.90
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$246.00
|
| Rate for Payer: Cash Price |
$461.25
|
| Rate for Payer: CDPHP Medicare |
$227.55
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$492.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$492.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$492.00
|
| Rate for Payer: EmblemHealth Medicaid |
$492.00
|
| Rate for Payer: EmblemHealth Medicare |
$209.10
|
| Rate for Payer: EmblemHealth Select Care |
$442.80
|
| Rate for Payer: Fidelis Medicare |
$246.00
|
| Rate for Payer: Galaxy Health Commercial |
$399.75
|
| Rate for Payer: Hamaspik Choice Medicare |
$246.00
|
| Rate for Payer: Humana Medicare |
$246.00
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$430.50
|
| Rate for Payer: Local 1199SEIU Medicare |
$282.90
|
| Rate for Payer: MVP Health Care of NY Commercial |
$461.25
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$346.25
|
| Rate for Payer: MVP Health Care of NY Medicare |
$258.30
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$92.25
|
| Rate for Payer: United Healthcare Medicare |
$246.00
|
| Rate for Payer: WellCare Medicare |
$338.25
|
|
|
SLCTV WND DEBRIDEM 20 CM OR <
|
Facility
|
IP
|
$615.00
|
|
|
Service Code
|
HCPCS 97597
|
| Hospital Charge Code |
4856724
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$399.75 |
| Max. Negotiated Rate |
$399.75 |
| Rate for Payer: Cash Price |
$461.25
|
| Rate for Payer: Galaxy Health Commercial |
$399.75
|
|
