|
STANDARDIZED COGNITIVE PERFORMANCE TESTING, PER HOUR
|
Facility
|
IP
|
$374.00
|
|
|
Service Code
|
HCPCS 96125 GN
|
| Hospital Charge Code |
4670259
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$243.10 |
| Max. Negotiated Rate |
$243.10 |
| Rate for Payer: Cash Price |
$280.50
|
| Rate for Payer: Galaxy Health Commercial |
$243.10
|
|
|
STANDARDIZED COGNITIVE PERFORMANCE TESTING, PER HOUR
|
Facility
|
OP
|
$374.00
|
|
|
Service Code
|
HCPCS 96125 GN
|
| Hospital Charge Code |
4670259
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$56.10 |
| Max. Negotiated Rate |
$433.74 |
| Rate for Payer: Aetna of NY Commercial |
$115.00
|
| Rate for Payer: Aetna of NY Medicare |
$172.04
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$149.60
|
| Rate for Payer: Cash Price |
$280.50
|
| Rate for Payer: Cash Price |
$280.50
|
| Rate for Payer: Cash Price |
$280.50
|
| Rate for Payer: CDPHP Medicare |
$138.38
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$299.20
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$242.09
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$201.74
|
| Rate for Payer: EmblemHealth Medicaid |
$201.74
|
| Rate for Payer: EmblemHealth Medicare |
$127.16
|
| Rate for Payer: EmblemHealth Select Care |
$269.28
|
| Rate for Payer: Fidelis Medicare |
$149.60
|
| Rate for Payer: Galaxy Health Commercial |
$243.10
|
| Rate for Payer: Galaxy Health Workers Comp |
$197.71
|
| Rate for Payer: Hamaspik Choice Medicaid |
$201.74
|
| Rate for Payer: Hamaspik Choice Medicare |
$149.60
|
| Rate for Payer: Humana Medicare |
$149.60
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$115.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$172.04
|
| Rate for Payer: MVP Health Care of NY Child Health Plus/Family Health Plus/HARP/Medicaid |
$211.83
|
| Rate for Payer: MVP Health Care of NY Commercial |
$187.00
|
| Rate for Payer: MVP Health Care of NY Essential Plan 1&2 |
$433.74
|
| Rate for Payer: MVP Health Care of NY Essential Plan 3&4 |
$433.74
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$141.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$157.08
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$161.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$56.10
|
| Rate for Payer: United Healthcare Commercial |
$161.00
|
| Rate for Payer: United Healthcare Medicare |
$149.60
|
| Rate for Payer: WellCare Child Health Plus/Family Health Plus/Medicaid |
$211.83
|
| Rate for Payer: WellCare Medicare |
$205.70
|
|
|
STANDARDIZED COGNITIVE PERFORMANCE TESTING, PER HOUR (MOD 59)
|
Facility
|
OP
|
$374.00
|
|
|
Service Code
|
HCPCS 96125 GN,59
|
| Hospital Charge Code |
4670297
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$56.10 |
| Max. Negotiated Rate |
$433.74 |
| Rate for Payer: Aetna of NY Commercial |
$115.00
|
| Rate for Payer: Aetna of NY Medicare |
$172.04
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$149.60
|
| Rate for Payer: Cash Price |
$280.50
|
| Rate for Payer: Cash Price |
$280.50
|
| Rate for Payer: Cash Price |
$280.50
|
| Rate for Payer: CDPHP Medicare |
$138.38
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$299.20
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$242.09
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$201.74
|
| Rate for Payer: EmblemHealth Medicaid |
$201.74
|
| Rate for Payer: EmblemHealth Medicare |
$127.16
|
| Rate for Payer: EmblemHealth Select Care |
$269.28
|
| Rate for Payer: Fidelis Medicare |
$149.60
|
| Rate for Payer: Galaxy Health Commercial |
$243.10
|
| Rate for Payer: Galaxy Health Workers Comp |
$197.71
|
| Rate for Payer: Hamaspik Choice Medicaid |
$201.74
|
| Rate for Payer: Hamaspik Choice Medicare |
$149.60
|
| Rate for Payer: Humana Medicare |
$149.60
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$115.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$172.04
|
| Rate for Payer: MVP Health Care of NY Child Health Plus/Family Health Plus/HARP/Medicaid |
$211.83
|
| Rate for Payer: MVP Health Care of NY Commercial |
$187.00
|
| Rate for Payer: MVP Health Care of NY Essential Plan 1&2 |
$433.74
|
| Rate for Payer: MVP Health Care of NY Essential Plan 3&4 |
$433.74
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$141.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$157.08
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$161.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$56.10
|
| Rate for Payer: United Healthcare Commercial |
$161.00
|
| Rate for Payer: United Healthcare Medicare |
$149.60
|
| Rate for Payer: WellCare Child Health Plus/Family Health Plus/Medicaid |
$211.83
|
| Rate for Payer: WellCare Medicare |
$205.70
|
|
|
STANDARDIZED COGNITIVE PERFORMANCE TESTING, PER HOUR (MOD 59)
|
Facility
|
IP
|
$374.00
|
|
|
Service Code
|
HCPCS 96125 GN,59
|
| Hospital Charge Code |
4670297
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$243.10 |
| Max. Negotiated Rate |
$243.10 |
| Rate for Payer: Cash Price |
$280.50
|
| Rate for Payer: Galaxy Health Commercial |
$243.10
|
|
|
STANDARDIZED COGNITIVE PERFORMANCE TESTING, PER HOUR (MOD 59 W KX)
|
Facility
|
IP
|
$374.00
|
|
|
Service Code
|
HCPCS 96125 GN,59,KX
|
| Hospital Charge Code |
4670313
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$243.10 |
| Max. Negotiated Rate |
$243.10 |
| Rate for Payer: Cash Price |
$280.50
|
| Rate for Payer: Galaxy Health Commercial |
$243.10
|
|
|
STANDARDIZED COGNITIVE PERFORMANCE TESTING, PER HOUR (MOD 59 W KX)
|
Facility
|
OP
|
$374.00
|
|
|
Service Code
|
HCPCS 96125 GN,59,KX
|
| Hospital Charge Code |
4670313
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$56.10 |
| Max. Negotiated Rate |
$433.74 |
| Rate for Payer: Aetna of NY Commercial |
$115.00
|
| Rate for Payer: Aetna of NY Medicare |
$172.04
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$149.60
|
| Rate for Payer: Cash Price |
$280.50
|
| Rate for Payer: Cash Price |
$280.50
|
| Rate for Payer: Cash Price |
$280.50
|
| Rate for Payer: CDPHP Medicare |
$138.38
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$299.20
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$242.09
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$201.74
|
| Rate for Payer: EmblemHealth Medicaid |
$201.74
|
| Rate for Payer: EmblemHealth Medicare |
$127.16
|
| Rate for Payer: EmblemHealth Select Care |
$269.28
|
| Rate for Payer: Fidelis Medicare |
$149.60
|
| Rate for Payer: Galaxy Health Commercial |
$243.10
|
| Rate for Payer: Galaxy Health Workers Comp |
$197.71
|
| Rate for Payer: Hamaspik Choice Medicaid |
$201.74
|
| Rate for Payer: Hamaspik Choice Medicare |
$149.60
|
| Rate for Payer: Humana Medicare |
$149.60
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$115.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$172.04
|
| Rate for Payer: MVP Health Care of NY Child Health Plus/Family Health Plus/HARP/Medicaid |
$211.83
|
| Rate for Payer: MVP Health Care of NY Commercial |
$187.00
|
| Rate for Payer: MVP Health Care of NY Essential Plan 1&2 |
$433.74
|
| Rate for Payer: MVP Health Care of NY Essential Plan 3&4 |
$433.74
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$141.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$157.08
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$161.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$56.10
|
| Rate for Payer: United Healthcare Commercial |
$161.00
|
| Rate for Payer: United Healthcare Medicare |
$149.60
|
| Rate for Payer: WellCare Child Health Plus/Family Health Plus/Medicaid |
$211.83
|
| Rate for Payer: WellCare Medicare |
$205.70
|
|
|
STANDARDIZED COGNITIVE PERFORMANCE TESTING, PER HOUR (W/ KX)
|
Facility
|
IP
|
$374.00
|
|
|
Service Code
|
HCPCS 96125 GN,KX
|
| Hospital Charge Code |
4670275
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$243.10 |
| Max. Negotiated Rate |
$243.10 |
| Rate for Payer: Cash Price |
$280.50
|
| Rate for Payer: Galaxy Health Commercial |
$243.10
|
|
|
STANDARDIZED COGNITIVE PERFORMANCE TESTING, PER HOUR (W/ KX)
|
Facility
|
OP
|
$374.00
|
|
|
Service Code
|
HCPCS 96125 GN,KX
|
| Hospital Charge Code |
4670275
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$56.10 |
| Max. Negotiated Rate |
$433.74 |
| Rate for Payer: Aetna of NY Commercial |
$115.00
|
| Rate for Payer: Aetna of NY Medicare |
$172.04
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$149.60
|
| Rate for Payer: Cash Price |
$280.50
|
| Rate for Payer: Cash Price |
$280.50
|
| Rate for Payer: Cash Price |
$280.50
|
| Rate for Payer: CDPHP Medicare |
$138.38
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$299.20
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$242.09
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$201.74
|
| Rate for Payer: EmblemHealth Medicaid |
$201.74
|
| Rate for Payer: EmblemHealth Medicare |
$127.16
|
| Rate for Payer: EmblemHealth Select Care |
$269.28
|
| Rate for Payer: Fidelis Medicare |
$149.60
|
| Rate for Payer: Galaxy Health Commercial |
$243.10
|
| Rate for Payer: Galaxy Health Workers Comp |
$197.71
|
| Rate for Payer: Hamaspik Choice Medicaid |
$201.74
|
| Rate for Payer: Hamaspik Choice Medicare |
$149.60
|
| Rate for Payer: Humana Medicare |
$149.60
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$115.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$172.04
|
| Rate for Payer: MVP Health Care of NY Child Health Plus/Family Health Plus/HARP/Medicaid |
$211.83
|
| Rate for Payer: MVP Health Care of NY Commercial |
$187.00
|
| Rate for Payer: MVP Health Care of NY Essential Plan 1&2 |
$433.74
|
| Rate for Payer: MVP Health Care of NY Essential Plan 3&4 |
$433.74
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$141.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$157.08
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$161.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$56.10
|
| Rate for Payer: United Healthcare Commercial |
$161.00
|
| Rate for Payer: United Healthcare Medicare |
$149.60
|
| Rate for Payer: WellCare Child Health Plus/Family Health Plus/Medicaid |
$211.83
|
| Rate for Payer: WellCare Medicare |
$205.70
|
|
|
STAPLER SKIN PRECISE SYSTEM
|
Facility
|
IP
|
$14.42
|
|
| Hospital Charge Code |
4472001
|
|
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
|
|
|
STAPLER SKIN PRECISE SYSTEM
|
Facility
|
OP
|
$14.42
|
|
| Hospital Charge Code |
4472001
|
|
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
|
|
|
STERILE 10IN STOCKINETTE
|
Facility
|
IP
|
$13.39
|
|
| Hospital Charge Code |
4471192
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$8.70 |
| Max. Negotiated Rate |
$8.70 |
| Rate for Payer: Cash Price |
$10.04
|
| Rate for Payer: Galaxy Health Commercial |
$8.70
|
|
|
STERILE 10IN STOCKINETTE
|
Facility
|
OP
|
$13.39
|
|
| Hospital Charge Code |
4471192
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$2.01 |
| Max. Negotiated Rate |
$10.71 |
| Rate for Payer: Aetna of NY Commercial |
$9.37
|
| Rate for Payer: Aetna of NY Medicare |
$6.16
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$5.36
|
| Rate for Payer: Cash Price |
$10.04
|
| Rate for Payer: CDPHP Medicare |
$4.95
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$10.71
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$10.71
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$10.71
|
| Rate for Payer: EmblemHealth Medicaid |
$10.71
|
| Rate for Payer: EmblemHealth Medicare |
$4.55
|
| Rate for Payer: EmblemHealth Select Care |
$9.64
|
| Rate for Payer: Fidelis Medicare |
$5.36
|
| Rate for Payer: Galaxy Health Commercial |
$8.70
|
| Rate for Payer: Hamaspik Choice Medicare |
$5.36
|
| Rate for Payer: Humana Medicare |
$5.36
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$9.37
|
| Rate for Payer: Local 1199SEIU Medicare |
$6.16
|
| Rate for Payer: MVP Health Care of NY Commercial |
$10.04
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$7.54
|
| Rate for Payer: MVP Health Care of NY Medicare |
$5.62
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$2.01
|
| Rate for Payer: United Healthcare Medicare |
$5.36
|
| Rate for Payer: WellCare Medicare |
$7.36
|
|
|
STERILE 3IN STOCKINETTE
|
Facility
|
IP
|
$13.39
|
|
| Hospital Charge Code |
4471191
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$8.70 |
| Max. Negotiated Rate |
$8.70 |
| Rate for Payer: Cash Price |
$10.04
|
| Rate for Payer: Galaxy Health Commercial |
$8.70
|
|
|
STERILE 3IN STOCKINETTE
|
Facility
|
OP
|
$13.39
|
|
| Hospital Charge Code |
4471191
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$2.01 |
| Max. Negotiated Rate |
$10.71 |
| Rate for Payer: Aetna of NY Commercial |
$9.37
|
| Rate for Payer: Aetna of NY Medicare |
$6.16
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$5.36
|
| Rate for Payer: Cash Price |
$10.04
|
| Rate for Payer: CDPHP Medicare |
$4.95
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$10.71
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$10.71
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$10.71
|
| Rate for Payer: EmblemHealth Medicaid |
$10.71
|
| Rate for Payer: EmblemHealth Medicare |
$4.55
|
| Rate for Payer: EmblemHealth Select Care |
$9.64
|
| Rate for Payer: Fidelis Medicare |
$5.36
|
| Rate for Payer: Galaxy Health Commercial |
$8.70
|
| Rate for Payer: Hamaspik Choice Medicare |
$5.36
|
| Rate for Payer: Humana Medicare |
$5.36
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$9.37
|
| Rate for Payer: Local 1199SEIU Medicare |
$6.16
|
| Rate for Payer: MVP Health Care of NY Commercial |
$10.04
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$7.54
|
| Rate for Payer: MVP Health Care of NY Medicare |
$5.62
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$2.01
|
| Rate for Payer: United Healthcare Medicare |
$5.36
|
| Rate for Payer: WellCare Medicare |
$7.36
|
|
|
STERILE 8IN STOCKINETTE
|
Facility
|
IP
|
$25.75
|
|
| Hospital Charge Code |
4471193
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$16.74 |
| Max. Negotiated Rate |
$16.74 |
| Rate for Payer: Cash Price |
$19.31
|
| Rate for Payer: Galaxy Health Commercial |
$16.74
|
|
|
STERILE 8IN STOCKINETTE
|
Facility
|
OP
|
$25.75
|
|
| Hospital Charge Code |
4471193
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$3.86 |
| Max. Negotiated Rate |
$20.60 |
| Rate for Payer: Aetna of NY Commercial |
$18.02
|
| Rate for Payer: Aetna of NY Medicare |
$11.85
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$10.30
|
| Rate for Payer: Cash Price |
$19.31
|
| Rate for Payer: CDPHP Medicare |
$9.53
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$20.60
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$20.60
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$20.60
|
| Rate for Payer: EmblemHealth Medicaid |
$20.60
|
| Rate for Payer: EmblemHealth Medicare |
$8.76
|
| Rate for Payer: EmblemHealth Select Care |
$18.54
|
| Rate for Payer: Fidelis Medicare |
$10.30
|
| Rate for Payer: Galaxy Health Commercial |
$16.74
|
| Rate for Payer: Hamaspik Choice Medicare |
$10.30
|
| Rate for Payer: Humana Medicare |
$10.30
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$18.02
|
| Rate for Payer: Local 1199SEIU Medicare |
$11.85
|
| Rate for Payer: MVP Health Care of NY Commercial |
$19.31
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$14.50
|
| Rate for Payer: MVP Health Care of NY Medicare |
$10.81
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$3.86
|
| Rate for Payer: United Healthcare Medicare |
$10.30
|
| Rate for Payer: WellCare Medicare |
$14.16
|
|
|
STERILE DRAPE-61050
|
Facility
|
OP
|
$23.69
|
|
| Hospital Charge Code |
4479225
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$3.55 |
| Max. Negotiated Rate |
$18.95 |
| Rate for Payer: Aetna of NY Commercial |
$16.58
|
| Rate for Payer: Aetna of NY Medicare |
$10.90
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$9.48
|
| Rate for Payer: Cash Price |
$17.77
|
| Rate for Payer: CDPHP Medicare |
$8.77
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$18.95
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$18.95
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$18.95
|
| Rate for Payer: EmblemHealth Medicaid |
$18.95
|
| Rate for Payer: EmblemHealth Medicare |
$8.05
|
| Rate for Payer: EmblemHealth Select Care |
$17.06
|
| Rate for Payer: Fidelis Medicare |
$9.48
|
| Rate for Payer: Galaxy Health Commercial |
$15.40
|
| Rate for Payer: Hamaspik Choice Medicare |
$9.48
|
| Rate for Payer: Humana Medicare |
$9.48
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$16.58
|
| Rate for Payer: Local 1199SEIU Medicare |
$10.90
|
| Rate for Payer: MVP Health Care of NY Commercial |
$17.77
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$13.34
|
| Rate for Payer: MVP Health Care of NY Medicare |
$9.95
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$3.55
|
| Rate for Payer: United Healthcare Medicare |
$9.48
|
| Rate for Payer: WellCare Medicare |
$13.03
|
|
|
STERILE DRAPE-61050
|
Facility
|
IP
|
$23.69
|
|
| Hospital Charge Code |
4479225
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$15.40 |
| Max. Negotiated Rate |
$15.40 |
| Rate for Payer: Cash Price |
$17.77
|
| Rate for Payer: Galaxy Health Commercial |
$15.40
|
|
|
STERILE WATER 1000 ML
|
Facility
|
OP
|
$19.57
|
|
|
Service Code
|
NDC 409713909
|
| Hospital Charge Code |
4450041
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$2.94 |
| Max. Negotiated Rate |
$15.66 |
| Rate for Payer: Aetna of NY Commercial |
$13.70
|
| Rate for Payer: Aetna of NY Medicare |
$9.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$7.83
|
| Rate for Payer: Cash Price |
$14.68
|
| Rate for Payer: CDPHP Medicare |
$7.24
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$15.66
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$15.66
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$15.66
|
| Rate for Payer: EmblemHealth Medicaid |
$15.66
|
| Rate for Payer: EmblemHealth Medicare |
$6.65
|
| Rate for Payer: EmblemHealth Select Care |
$14.09
|
| Rate for Payer: Fidelis Medicare |
$7.83
|
| Rate for Payer: Galaxy Health Commercial |
$12.72
|
| Rate for Payer: Hamaspik Choice Medicare |
$7.83
|
| Rate for Payer: Humana Medicare |
$7.83
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$13.70
|
| Rate for Payer: Local 1199SEIU Medicare |
$9.00
|
| Rate for Payer: MVP Health Care of NY Commercial |
$14.68
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$11.02
|
| Rate for Payer: MVP Health Care of NY Medicare |
$8.22
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$2.94
|
| Rate for Payer: United Healthcare Medicare |
$7.83
|
| Rate for Payer: WellCare Medicare |
$10.76
|
|
|
STERILE WATER 1000 ML
|
Facility
|
IP
|
$19.57
|
|
|
Service Code
|
NDC 409713909
|
| Hospital Charge Code |
4450041
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$12.72 |
| Max. Negotiated Rate |
$12.72 |
| Rate for Payer: Cash Price |
$14.68
|
| Rate for Payer: Galaxy Health Commercial |
$12.72
|
|
|
STIRRUPS-52710
|
Facility
|
OP
|
$15.45
|
|
| Hospital Charge Code |
4479226
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$2.32 |
| Max. Negotiated Rate |
$12.36 |
| Rate for Payer: Aetna of NY Commercial |
$10.81
|
| Rate for Payer: Aetna of NY Medicare |
$7.11
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$6.18
|
| Rate for Payer: Cash Price |
$11.59
|
| Rate for Payer: CDPHP Medicare |
$5.72
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$12.36
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$12.36
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$12.36
|
| Rate for Payer: EmblemHealth Medicaid |
$12.36
|
| Rate for Payer: EmblemHealth Medicare |
$5.25
|
| Rate for Payer: EmblemHealth Select Care |
$11.12
|
| Rate for Payer: Fidelis Medicare |
$6.18
|
| Rate for Payer: Galaxy Health Commercial |
$10.04
|
| Rate for Payer: Hamaspik Choice Medicare |
$6.18
|
| Rate for Payer: Humana Medicare |
$6.18
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$10.81
|
| Rate for Payer: Local 1199SEIU Medicare |
$7.11
|
| Rate for Payer: MVP Health Care of NY Commercial |
$11.59
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$8.70
|
| Rate for Payer: MVP Health Care of NY Medicare |
$6.49
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$2.32
|
| Rate for Payer: United Healthcare Medicare |
$6.18
|
| Rate for Payer: WellCare Medicare |
$8.50
|
|
|
STIRRUPS-52710
|
Facility
|
IP
|
$15.45
|
|
| Hospital Charge Code |
4479226
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$10.04 |
| Max. Negotiated Rate |
$10.04 |
| Rate for Payer: Cash Price |
$11.59
|
| Rate for Payer: Galaxy Health Commercial |
$10.04
|
|
|
STIRRUP WITH SLIP RING#52712
|
Facility
|
IP
|
$16.48
|
|
| Hospital Charge Code |
4479276
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$10.71 |
| Max. Negotiated Rate |
$10.71 |
| Rate for Payer: Cash Price |
$12.36
|
| Rate for Payer: Galaxy Health Commercial |
$10.71
|
|
|
STIRRUP WITH SLIP RING#52712
|
Facility
|
OP
|
$16.48
|
|
| Hospital Charge Code |
4479276
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$2.47 |
| Max. Negotiated Rate |
$13.18 |
| Rate for Payer: Aetna of NY Commercial |
$11.54
|
| Rate for Payer: Aetna of NY Medicare |
$7.58
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$6.59
|
| Rate for Payer: Cash Price |
$12.36
|
| Rate for Payer: CDPHP Medicare |
$6.10
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$13.18
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$13.18
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$13.18
|
| Rate for Payer: EmblemHealth Medicaid |
$13.18
|
| Rate for Payer: EmblemHealth Medicare |
$5.60
|
| Rate for Payer: EmblemHealth Select Care |
$11.87
|
| Rate for Payer: Fidelis Medicare |
$6.59
|
| Rate for Payer: Galaxy Health Commercial |
$10.71
|
| Rate for Payer: Hamaspik Choice Medicare |
$6.59
|
| Rate for Payer: Humana Medicare |
$6.59
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$11.54
|
| Rate for Payer: Local 1199SEIU Medicare |
$7.58
|
| Rate for Payer: MVP Health Care of NY Commercial |
$12.36
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$9.28
|
| Rate for Payer: MVP Health Care of NY Medicare |
$6.92
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$2.47
|
| Rate for Payer: United Healthcare Medicare |
$6.59
|
| Rate for Payer: WellCare Medicare |
$9.06
|
|
|
STOCKINETTE,IMPERVIOUS,LARGE
|
Facility
|
IP
|
$10.30
|
|
| Hospital Charge Code |
4471165
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$6.70 |
| Max. Negotiated Rate |
$6.70 |
| Rate for Payer: Cash Price |
$7.72
|
| Rate for Payer: Galaxy Health Commercial |
$6.70
|
|
