|
SMALL RIGHT COMFORTFORM WRIST
|
Facility
|
IP
|
$27.81
|
|
| Hospital Charge Code |
4471565
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$18.08 |
| Max. Negotiated Rate |
$18.08 |
| Rate for Payer: Cash Price |
$20.86
|
| Rate for Payer: Galaxy Health Commercial |
$18.08
|
|
|
SMALL RIGHT COMFORTFORM WRIST
|
Facility
|
OP
|
$27.81
|
|
| Hospital Charge Code |
4471565
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$4.17 |
| Max. Negotiated Rate |
$22.25 |
| Rate for Payer: Aetna of NY Commercial |
$19.47
|
| Rate for Payer: Aetna of NY Medicare |
$12.79
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$11.12
|
| Rate for Payer: Cash Price |
$20.86
|
| Rate for Payer: CDPHP Medicare |
$10.29
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$22.25
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$22.25
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$22.25
|
| Rate for Payer: EmblemHealth Medicaid |
$22.25
|
| Rate for Payer: EmblemHealth Medicare |
$9.46
|
| Rate for Payer: EmblemHealth Select Care |
$20.02
|
| Rate for Payer: Fidelis Medicare |
$11.12
|
| Rate for Payer: Galaxy Health Commercial |
$18.08
|
| Rate for Payer: Hamaspik Choice Medicare |
$11.12
|
| Rate for Payer: Humana Medicare |
$11.12
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$19.47
|
| Rate for Payer: Local 1199SEIU Medicare |
$12.79
|
| Rate for Payer: MVP Health Care of NY Commercial |
$20.86
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$15.66
|
| Rate for Payer: MVP Health Care of NY Medicare |
$11.68
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$4.17
|
| Rate for Payer: United Healthcare Medicare |
$11.12
|
| Rate for Payer: WellCare Medicare |
$15.30
|
|
|
SMALL SPECIALTY ARM SLING
|
Facility
|
IP
|
$14.42
|
|
| Hospital Charge Code |
4471556
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$9.37 |
| Max. Negotiated Rate |
$9.37 |
| Rate for Payer: Cash Price |
$10.82
|
| Rate for Payer: Galaxy Health Commercial |
$9.37
|
|
|
SMALL SPECIALTY ARM SLING
|
Facility
|
OP
|
$14.42
|
|
| Hospital Charge Code |
4471556
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$2.16 |
| Max. Negotiated Rate |
$11.54 |
| Rate for Payer: Aetna of NY Commercial |
$10.09
|
| Rate for Payer: Aetna of NY Medicare |
$6.63
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$5.77
|
| Rate for Payer: Cash Price |
$10.82
|
| Rate for Payer: CDPHP Medicare |
$5.34
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$11.54
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$11.54
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$11.54
|
| Rate for Payer: EmblemHealth Medicaid |
$11.54
|
| Rate for Payer: EmblemHealth Medicare |
$4.90
|
| Rate for Payer: EmblemHealth Select Care |
$10.38
|
| Rate for Payer: Fidelis Medicare |
$5.77
|
| Rate for Payer: Galaxy Health Commercial |
$9.37
|
| Rate for Payer: Hamaspik Choice Medicare |
$5.77
|
| Rate for Payer: Humana Medicare |
$5.77
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$10.09
|
| Rate for Payer: Local 1199SEIU Medicare |
$6.63
|
| Rate for Payer: MVP Health Care of NY Commercial |
$10.81
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$8.12
|
| Rate for Payer: MVP Health Care of NY Medicare |
$6.06
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$2.16
|
| Rate for Payer: United Healthcare Medicare |
$5.77
|
| Rate for Payer: WellCare Medicare |
$7.93
|
|
|
SMALL STOCKING ANTI-EMB THIGH
|
Facility
|
IP
|
$42.23
|
|
| Hospital Charge Code |
4471180
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$27.45 |
| Max. Negotiated Rate |
$27.45 |
| Rate for Payer: Cash Price |
$31.67
|
| Rate for Payer: Galaxy Health Commercial |
$27.45
|
|
|
SMALL STOCKING ANTI-EMB THIGH
|
Facility
|
OP
|
$42.23
|
|
| Hospital Charge Code |
4471180
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$6.33 |
| Max. Negotiated Rate |
$33.78 |
| Rate for Payer: Aetna of NY Commercial |
$29.56
|
| Rate for Payer: Aetna of NY Medicare |
$19.43
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$16.89
|
| Rate for Payer: Cash Price |
$31.67
|
| Rate for Payer: CDPHP Medicare |
$15.63
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$33.78
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$33.78
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$33.78
|
| Rate for Payer: EmblemHealth Medicaid |
$33.78
|
| Rate for Payer: EmblemHealth Medicare |
$14.36
|
| Rate for Payer: EmblemHealth Select Care |
$30.41
|
| Rate for Payer: Fidelis Medicare |
$16.89
|
| Rate for Payer: Galaxy Health Commercial |
$27.45
|
| Rate for Payer: Hamaspik Choice Medicare |
$16.89
|
| Rate for Payer: Humana Medicare |
$16.89
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$29.56
|
| Rate for Payer: Local 1199SEIU Medicare |
$19.43
|
| Rate for Payer: MVP Health Care of NY Commercial |
$31.67
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$23.78
|
| Rate for Payer: MVP Health Care of NY Medicare |
$17.74
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$6.33
|
| Rate for Payer: United Healthcare Medicare |
$16.89
|
| Rate for Payer: WellCare Medicare |
$23.23
|
|
|
SMALL WASHER
|
Facility
|
IP
|
$89.61
|
|
| Hospital Charge Code |
4472235
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$40.32 |
| Max. Negotiated Rate |
$62.73 |
| Rate for Payer: Aetna of NY Commercial |
$62.73
|
| Rate for Payer: Cash Price |
$67.21
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$44.80
|
| Rate for Payer: EmblemHealth Select Care |
$44.80
|
| Rate for Payer: Galaxy Health Commercial |
$58.25
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$62.73
|
| Rate for Payer: Multiplan Commercial |
$40.32
|
| Rate for Payer: MVP Health Care of NY Commercial |
$58.25
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$58.25
|
| Rate for Payer: WellCare Medicare |
$49.29
|
|
|
SMALL WASHER
|
Facility
|
OP
|
$89.61
|
|
| Hospital Charge Code |
4472235
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$13.44 |
| Max. Negotiated Rate |
$71.69 |
| Rate for Payer: Aetna of NY Commercial |
$62.73
|
| Rate for Payer: Aetna of NY Medicare |
$41.22
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$35.84
|
| Rate for Payer: Cash Price |
$67.21
|
| Rate for Payer: CDPHP Medicare |
$33.16
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$44.80
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$71.69
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$71.69
|
| Rate for Payer: EmblemHealth Medicaid |
$71.69
|
| Rate for Payer: EmblemHealth Medicare |
$30.47
|
| Rate for Payer: EmblemHealth Select Care |
$44.80
|
| Rate for Payer: Fidelis Medicare |
$35.84
|
| Rate for Payer: Galaxy Health Commercial |
$58.25
|
| Rate for Payer: Hamaspik Choice Medicare |
$35.84
|
| Rate for Payer: Humana Medicare |
$35.84
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$62.73
|
| Rate for Payer: Local 1199SEIU Medicare |
$41.22
|
| Rate for Payer: MVP Health Care of NY Commercial |
$58.25
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$58.25
|
| Rate for Payer: MVP Health Care of NY Medicare |
$37.64
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$13.44
|
| Rate for Payer: United Healthcare Medicare |
$35.84
|
| Rate for Payer: WellCare Medicare |
$49.29
|
|
|
SMARK-CELERO
|
Facility
|
IP
|
$230.72
|
|
| Hospital Charge Code |
4473015
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$149.97 |
| Max. Negotiated Rate |
$149.97 |
| Rate for Payer: Cash Price |
$173.04
|
| Rate for Payer: Galaxy Health Commercial |
$149.97
|
|
|
SMARK-CELERO
|
Facility
|
OP
|
$230.72
|
|
| Hospital Charge Code |
4473015
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$34.61 |
| Max. Negotiated Rate |
$184.58 |
| Rate for Payer: Aetna of NY Commercial |
$161.50
|
| Rate for Payer: Aetna of NY Medicare |
$106.13
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$92.29
|
| Rate for Payer: Cash Price |
$173.04
|
| Rate for Payer: CDPHP Medicare |
$85.37
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$184.58
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$184.58
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$184.58
|
| Rate for Payer: EmblemHealth Medicaid |
$184.58
|
| Rate for Payer: EmblemHealth Medicare |
$78.44
|
| Rate for Payer: EmblemHealth Select Care |
$166.12
|
| Rate for Payer: Fidelis Medicare |
$92.29
|
| Rate for Payer: Galaxy Health Commercial |
$149.97
|
| Rate for Payer: Hamaspik Choice Medicare |
$92.29
|
| Rate for Payer: Humana Medicare |
$92.29
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$161.50
|
| Rate for Payer: Local 1199SEIU Medicare |
$106.13
|
| Rate for Payer: MVP Health Care of NY Commercial |
$173.04
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$129.90
|
| Rate for Payer: MVP Health Care of NY Medicare |
$96.90
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$34.61
|
| Rate for Payer: United Healthcare Medicare |
$92.29
|
| Rate for Payer: WellCare Medicare |
$126.90
|
|
|
SMPL RPR SCALP/NECK/AX/GENIT/TRUNK 20.1-30.0CM
|
Facility
|
OP
|
$1,246.00
|
|
|
Service Code
|
HCPCS 12006
|
| Hospital Charge Code |
4609597
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$186.90 |
| Max. Negotiated Rate |
$1,234.00 |
| Rate for Payer: Aetna of NY Commercial |
$1,000.00
|
| Rate for Payer: Aetna of NY Medicare |
$573.16
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$498.40
|
| Rate for Payer: Cash Price |
$934.50
|
| Rate for Payer: Cash Price |
$934.50
|
| Rate for Payer: Cash Price |
$934.50
|
| Rate for Payer: CDPHP Medicare |
$461.02
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$1,206.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$996.80
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$996.80
|
| Rate for Payer: EmblemHealth Medicaid |
$996.80
|
| Rate for Payer: EmblemHealth Medicare |
$423.64
|
| Rate for Payer: EmblemHealth Select Care |
$1,085.00
|
| Rate for Payer: Fidelis Medicare |
$498.40
|
| Rate for Payer: Galaxy Health Commercial |
$809.90
|
| Rate for Payer: Hamaspik Choice Medicare |
$498.40
|
| Rate for Payer: Humana Medicare |
$498.40
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,000.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$573.16
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,234.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$925.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$523.32
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$1,009.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$186.90
|
| Rate for Payer: United Healthcare Commercial |
$1,009.00
|
| Rate for Payer: United Healthcare Medicare |
$498.40
|
| Rate for Payer: WellCare Medicare |
$685.30
|
|
|
SMPL RPR SCALP/NECK/AX/GENIT/TRUNK 20.1-30.0CM
|
Facility
|
IP
|
$1,246.00
|
|
|
Service Code
|
HCPCS 12006
|
| Hospital Charge Code |
4609597
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$809.90 |
| Max. Negotiated Rate |
$809.90 |
| Rate for Payer: Cash Price |
$934.50
|
| Rate for Payer: Galaxy Health Commercial |
$809.90
|
|
|
SMR PRIM SRC CPLX SPEC STAIN OVA&PARASITS
|
Facility
|
OP
|
$54.00
|
|
|
Service Code
|
HCPCS 87209
|
| Hospital Charge Code |
4302024
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.10 |
| Max. Negotiated Rate |
$43.20 |
| Rate for Payer: Aetna of NY Commercial |
$35.10
|
| Rate for Payer: Aetna of NY Medicare |
$24.84
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$21.60
|
| Rate for Payer: Cash Price |
$40.50
|
| Rate for Payer: CDPHP Medicare |
$19.98
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$32.40
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$43.20
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$43.20
|
| Rate for Payer: EmblemHealth Medicaid |
$43.20
|
| Rate for Payer: EmblemHealth Medicare |
$18.36
|
| Rate for Payer: EmblemHealth Select Care |
$32.40
|
| Rate for Payer: Fidelis Medicare |
$21.60
|
| Rate for Payer: Galaxy Health Commercial |
$35.10
|
| Rate for Payer: Hamaspik Choice Medicare |
$21.60
|
| Rate for Payer: Humana Medicare |
$21.60
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$35.10
|
| Rate for Payer: Local 1199SEIU Medicare |
$24.84
|
| Rate for Payer: MVP Health Care of NY Commercial |
$40.50
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$30.40
|
| Rate for Payer: MVP Health Care of NY Medicare |
$22.68
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$40.50
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$8.10
|
| Rate for Payer: United Healthcare Commercial |
$40.50
|
| Rate for Payer: United Healthcare Medicare |
$21.60
|
| Rate for Payer: WellCare Medicare |
$29.70
|
|
|
SMR PRIM SRC CPLX SPEC STAIN OVA&PARASITS
|
Facility
|
IP
|
$54.00
|
|
|
Service Code
|
HCPCS 87209
|
| Hospital Charge Code |
4302024
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$35.10 |
| Max. Negotiated Rate |
$35.10 |
| Rate for Payer: Cash Price |
$40.50
|
| Rate for Payer: Galaxy Health Commercial |
$35.10
|
|
|
SMR PRIM SRC GRAM/GIEMSA STAIN BCT FUNGI/CELL
|
Facility
|
OP
|
$16.00
|
|
|
Service Code
|
HCPCS 87205
|
| Hospital Charge Code |
4300301
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$2.40 |
| Max. Negotiated Rate |
$12.80 |
| Rate for Payer: Aetna of NY Commercial |
$10.40
|
| Rate for Payer: Aetna of NY Medicare |
$7.36
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$6.40
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: CDPHP Medicare |
$5.92
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$9.60
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$12.80
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$12.80
|
| Rate for Payer: EmblemHealth Medicaid |
$12.80
|
| Rate for Payer: EmblemHealth Medicare |
$5.44
|
| Rate for Payer: EmblemHealth Select Care |
$9.60
|
| Rate for Payer: Fidelis Medicare |
$6.40
|
| Rate for Payer: Galaxy Health Commercial |
$10.40
|
| Rate for Payer: Hamaspik Choice Medicare |
$6.40
|
| Rate for Payer: Humana Medicare |
$6.40
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$10.40
|
| Rate for Payer: Local 1199SEIU Medicare |
$7.36
|
| Rate for Payer: MVP Health Care of NY Commercial |
$12.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$9.01
|
| Rate for Payer: MVP Health Care of NY Medicare |
$6.72
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$12.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$2.40
|
| Rate for Payer: United Healthcare Commercial |
$12.00
|
| Rate for Payer: United Healthcare Medicare |
$6.40
|
| Rate for Payer: WellCare Medicare |
$8.80
|
|
|
SMR PRIM SRC GRAM/GIEMSA STAIN BCT FUNGI/CELL
|
Facility
|
IP
|
$16.00
|
|
|
Service Code
|
HCPCS 87205
|
| Hospital Charge Code |
4300301
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$10.40 |
| Max. Negotiated Rate |
$10.40 |
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Galaxy Health Commercial |
$10.40
|
|
|
SMR PRIM SRC SPEC STAIN BODIES/PARASITS
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
HCPCS 87207
|
| Hospital Charge Code |
4300549
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$2.70 |
| Max. Negotiated Rate |
$14.40 |
| Rate for Payer: Aetna of NY Commercial |
$11.70
|
| Rate for Payer: Aetna of NY Medicare |
$8.28
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$7.20
|
| Rate for Payer: Cash Price |
$13.50
|
| Rate for Payer: CDPHP Medicare |
$6.66
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$10.80
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$14.40
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$14.40
|
| Rate for Payer: EmblemHealth Medicaid |
$14.40
|
| Rate for Payer: EmblemHealth Medicare |
$6.12
|
| Rate for Payer: EmblemHealth Select Care |
$10.80
|
| Rate for Payer: Fidelis Medicare |
$7.20
|
| Rate for Payer: Galaxy Health Commercial |
$11.70
|
| Rate for Payer: Hamaspik Choice Medicare |
$7.20
|
| Rate for Payer: Humana Medicare |
$7.20
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$11.70
|
| Rate for Payer: Local 1199SEIU Medicare |
$8.28
|
| Rate for Payer: MVP Health Care of NY Commercial |
$13.50
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$10.13
|
| Rate for Payer: MVP Health Care of NY Medicare |
$7.56
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$13.50
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$2.70
|
| Rate for Payer: United Healthcare Commercial |
$13.50
|
| Rate for Payer: United Healthcare Medicare |
$7.20
|
| Rate for Payer: WellCare Medicare |
$9.90
|
|
|
SMR PRIM SRC SPEC STAIN BODIES/PARASITS
|
Facility
|
IP
|
$18.00
|
|
|
Service Code
|
HCPCS 87207
|
| Hospital Charge Code |
4300549
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$11.70 |
| Max. Negotiated Rate |
$11.70 |
| Rate for Payer: Cash Price |
$13.50
|
| Rate for Payer: Galaxy Health Commercial |
$11.70
|
|
|
SMZ-TMP CONCENTRATE (M.D.V.) 80 MG/ML-16 MG/ML
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
4409186
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.90 |
| Max. Negotiated Rate |
$4.80 |
| Rate for Payer: Aetna of NY Medicare |
$2.76
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$2.40
|
| Rate for Payer: Cash Price |
$4.50
|
| 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 |
$2.40
|
| Rate for Payer: Galaxy Health Commercial |
$3.90
|
| Rate for Payer: Hamaspik Choice Medicare |
$2.40
|
| Rate for Payer: Humana Medicare |
$2.40
|
| 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 |
$2.52
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$0.90
|
| Rate for Payer: United Healthcare Medicare |
$2.40
|
| Rate for Payer: WellCare Medicare |
$3.30
|
|
|
SMZ-TMP CONCENTRATE (M.D.V.) 80 MG/ML-16 MG/ML
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
4409186
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.30 |
| Max. Negotiated Rate |
$3.90 |
| Rate for Payer: Aetna of NY Commercial |
$3.30
|
| Rate for Payer: Cash Price |
$4.50
|
| Rate for Payer: Galaxy Health Commercial |
$3.90
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$3.30
|
| Rate for Payer: WellCare Medicare |
$3.30
|
|
|
SMZ-TMP SUSP
|
Facility
|
OP
|
$6.95
|
|
|
Service Code
|
NDC 65862049647
|
| Hospital Charge Code |
4408978
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.04 |
| Max. Negotiated Rate |
$5.56 |
| Rate for Payer: Aetna of NY Commercial |
$4.87
|
| Rate for Payer: Aetna of NY Medicare |
$3.20
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$2.78
|
| Rate for Payer: Cash Price |
$5.21
|
| Rate for Payer: CDPHP Medicare |
$2.57
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$5.56
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$5.56
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$5.56
|
| Rate for Payer: EmblemHealth Medicaid |
$5.56
|
| Rate for Payer: EmblemHealth Medicare |
$2.36
|
| Rate for Payer: EmblemHealth Select Care |
$5.00
|
| Rate for Payer: Fidelis Medicare |
$2.78
|
| Rate for Payer: Galaxy Health Commercial |
$4.52
|
| Rate for Payer: Hamaspik Choice Medicare |
$2.78
|
| Rate for Payer: Humana Medicare |
$2.78
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$4.87
|
| Rate for Payer: Local 1199SEIU Medicare |
$3.20
|
| Rate for Payer: MVP Health Care of NY Commercial |
$5.21
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$3.91
|
| Rate for Payer: MVP Health Care of NY Medicare |
$2.92
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$1.04
|
| Rate for Payer: United Healthcare Medicare |
$2.78
|
| Rate for Payer: WellCare Medicare |
$3.82
|
|
|
SMZ-TMP SUSP
|
Facility
|
IP
|
$6.95
|
|
|
Service Code
|
NDC 65862049647
|
| Hospital Charge Code |
4408978
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.82 |
| Max. Negotiated Rate |
$4.52 |
| Rate for Payer: Cash Price |
$5.21
|
| Rate for Payer: Galaxy Health Commercial |
$4.52
|
| Rate for Payer: WellCare Medicare |
$3.82
|
|
|
SNARE MASTER PLUS ELECTROSURGICAL SNARE (SD-400U-15)
|
Facility
|
OP
|
$595.00
|
|
| Hospital Charge Code |
4473043
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$89.25 |
| Max. Negotiated Rate |
$476.00 |
| Rate for Payer: Aetna of NY Commercial |
$416.50
|
| Rate for Payer: Aetna of NY Medicare |
$273.70
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$238.00
|
| Rate for Payer: Cash Price |
$446.25
|
| Rate for Payer: CDPHP Medicare |
$220.15
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$476.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$476.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$476.00
|
| Rate for Payer: EmblemHealth Medicaid |
$476.00
|
| Rate for Payer: EmblemHealth Medicare |
$202.30
|
| Rate for Payer: EmblemHealth Select Care |
$428.40
|
| Rate for Payer: Fidelis Medicare |
$238.00
|
| Rate for Payer: Galaxy Health Commercial |
$386.75
|
| Rate for Payer: Hamaspik Choice Medicare |
$238.00
|
| Rate for Payer: Humana Medicare |
$238.00
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$416.50
|
| Rate for Payer: Local 1199SEIU Medicare |
$273.70
|
| Rate for Payer: MVP Health Care of NY Commercial |
$446.25
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$334.99
|
| Rate for Payer: MVP Health Care of NY Medicare |
$249.90
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$89.25
|
| Rate for Payer: United Healthcare Medicare |
$238.00
|
| Rate for Payer: WellCare Medicare |
$327.25
|
|
|
SNARE MASTER PLUS ELECTROSURGICAL SNARE (SD-400U-15)
|
Facility
|
IP
|
$595.00
|
|
| Hospital Charge Code |
4473043
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$386.75 |
| Max. Negotiated Rate |
$386.75 |
| Rate for Payer: Cash Price |
$446.25
|
| Rate for Payer: Galaxy Health Commercial |
$386.75
|
|
|
SODIUM BICARBONATE 0.5MEQ/ML SDV 25X5ML
|
Facility
|
OP
|
$6.18
|
|
|
Service Code
|
NDC 63323002605
|
| Hospital Charge Code |
4400705
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.93 |
| Max. Negotiated Rate |
$4.94 |
| 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) Medicare |
$2.47
|
| Rate for Payer: Cash Price |
$4.64
|
| 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 |
$2.47
|
| Rate for Payer: Galaxy Health Commercial |
$4.02
|
| Rate for Payer: Hamaspik Choice Medicare |
$2.47
|
| Rate for Payer: Humana Medicare |
$2.47
|
| 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 |
$4.63
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$3.48
|
| Rate for Payer: MVP Health Care of NY Medicare |
$2.60
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$0.93
|
| Rate for Payer: United Healthcare Medicare |
$2.47
|
| Rate for Payer: WellCare Medicare |
$3.40
|
|
