|
SUCRALFATE SUSP
|
Facility
|
OP
|
$24.21
|
|
|
Service Code
|
NDC 66689079050
|
| Hospital Charge Code |
4408976
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.63 |
| Max. Negotiated Rate |
$19.37 |
| Rate for Payer: Aetna of NY Commercial |
$16.95
|
| Rate for Payer: Aetna of NY Medicare |
$11.14
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$9.68
|
| Rate for Payer: Cash Price |
$18.16
|
| Rate for Payer: CDPHP Medicare |
$8.96
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$19.37
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$19.37
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$19.37
|
| Rate for Payer: EmblemHealth Medicaid |
$19.37
|
| Rate for Payer: EmblemHealth Medicare |
$8.23
|
| Rate for Payer: EmblemHealth Select Care |
$17.43
|
| Rate for Payer: Fidelis Medicare |
$9.68
|
| Rate for Payer: Galaxy Health Commercial |
$15.74
|
| Rate for Payer: Hamaspik Choice Medicare |
$9.68
|
| Rate for Payer: Humana Medicare |
$9.68
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$16.95
|
| Rate for Payer: Local 1199SEIU Medicare |
$11.14
|
| Rate for Payer: MVP Health Care of NY Commercial |
$18.16
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$13.63
|
| Rate for Payer: MVP Health Care of NY Medicare |
$10.17
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$3.63
|
| Rate for Payer: United Healthcare Medicare |
$9.68
|
| Rate for Payer: WellCare Medicare |
$13.32
|
|
|
SULFACETAMIDE SODIUM 0.1 DROP 15 ML
|
Facility
|
IP
|
$188.49
|
|
|
Service Code
|
NDC 24208067004
|
| Hospital Charge Code |
4400727
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$103.67 |
| Max. Negotiated Rate |
$122.52 |
| Rate for Payer: Cash Price |
$141.37
|
| Rate for Payer: Galaxy Health Commercial |
$122.52
|
| Rate for Payer: WellCare Medicare |
$103.67
|
|
|
SULFACETAMIDE SODIUM 0.1 DROP 15 ML
|
Facility
|
OP
|
$188.49
|
|
|
Service Code
|
NDC 24208067004
|
| Hospital Charge Code |
4400727
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$28.27 |
| Max. Negotiated Rate |
$150.79 |
| Rate for Payer: Aetna of NY Commercial |
$131.94
|
| Rate for Payer: Aetna of NY Medicare |
$86.71
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$75.40
|
| Rate for Payer: Cash Price |
$141.37
|
| Rate for Payer: CDPHP Medicare |
$69.74
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$150.79
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$150.79
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$150.79
|
| Rate for Payer: EmblemHealth Medicaid |
$150.79
|
| Rate for Payer: EmblemHealth Medicare |
$64.09
|
| Rate for Payer: EmblemHealth Select Care |
$135.71
|
| Rate for Payer: Fidelis Medicare |
$75.40
|
| Rate for Payer: Galaxy Health Commercial |
$122.52
|
| Rate for Payer: Hamaspik Choice Medicare |
$75.40
|
| Rate for Payer: Humana Medicare |
$75.40
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$131.94
|
| Rate for Payer: Local 1199SEIU Medicare |
$86.71
|
| Rate for Payer: MVP Health Care of NY Commercial |
$141.37
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$106.12
|
| Rate for Payer: MVP Health Care of NY Medicare |
$79.17
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$28.27
|
| Rate for Payer: United Healthcare Medicare |
$75.40
|
| Rate for Payer: WellCare Medicare |
$103.67
|
|
|
SULFAMETHOXAZOLE AND TRIMETHOPRIM
|
Facility
|
OP
|
$6.18
|
|
| Hospital Charge Code |
4408938
|
|
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
|
|
|
SULFAMETHOXAZOLE AND TRIMETHOPRIM
|
Facility
|
IP
|
$6.18
|
|
| Hospital Charge Code |
4408938
|
|
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
|
|
|
SULFAMETHOXAZOLE/TMP 800-160MG TABS 10X1
|
Facility
|
IP
|
$6.18
|
|
|
Service Code
|
NDC 904272561
|
| Hospital Charge Code |
4400728
|
|
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
|
|
|
SULFAMETHOXAZOLE/TMP 800-160MG TABS 10X1
|
Facility
|
OP
|
$6.18
|
|
|
Service Code
|
NDC 904272561
|
| Hospital Charge Code |
4400728
|
|
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
|
|
|
SULFAMETHOXAZOLE-TMP SUSP 200 mL, 20 mL
|
Facility
|
OP
|
$30.00
|
|
|
Service Code
|
NDC 121085340
|
| Hospital Charge Code |
4401487
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.50 |
| Max. Negotiated Rate |
$24.00 |
| Rate for Payer: Aetna of NY Commercial |
$21.00
|
| Rate for Payer: Aetna of NY Medicare |
$13.80
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$12.00
|
| Rate for Payer: Cash Price |
$22.50
|
| Rate for Payer: CDPHP Medicare |
$11.10
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$24.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$24.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$24.00
|
| Rate for Payer: EmblemHealth Medicaid |
$24.00
|
| Rate for Payer: EmblemHealth Medicare |
$10.20
|
| Rate for Payer: EmblemHealth Select Care |
$21.60
|
| Rate for Payer: Fidelis Medicare |
$12.00
|
| Rate for Payer: Galaxy Health Commercial |
$19.50
|
| Rate for Payer: Hamaspik Choice Medicare |
$12.00
|
| Rate for Payer: Humana Medicare |
$12.00
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$21.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$13.80
|
| Rate for Payer: MVP Health Care of NY Commercial |
$22.50
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$16.89
|
| Rate for Payer: MVP Health Care of NY Medicare |
$12.60
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$4.50
|
| Rate for Payer: United Healthcare Medicare |
$12.00
|
| Rate for Payer: WellCare Medicare |
$16.50
|
|
|
SULFAMETHOXAZOLE-TMP SUSP 200 mL, 20 mL
|
Facility
|
IP
|
$30.00
|
|
|
Service Code
|
NDC 121085340
|
| Hospital Charge Code |
4401487
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.50 |
| Max. Negotiated Rate |
$19.50 |
| Rate for Payer: Cash Price |
$22.50
|
| Rate for Payer: Galaxy Health Commercial |
$19.50
|
| Rate for Payer: WellCare Medicare |
$16.50
|
|
|
SULFAMETHOXAZOLE/TRIMETHOPRIM INJECTION 400/80, 5 ML INJECTION
|
Facility
|
IP
|
$20.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
4401293
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.00 |
| Max. Negotiated Rate |
$13.00 |
| Rate for Payer: Aetna of NY Commercial |
$11.00
|
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Galaxy Health Commercial |
$13.00
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$11.00
|
| Rate for Payer: WellCare Medicare |
$11.00
|
|
|
SULFAMETHOXAZOLE/TRIMETHOPRIM INJECTION 400/80, 5 ML INJECTION
|
Facility
|
OP
|
$20.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
4401293
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.00 |
| Max. Negotiated Rate |
$16.00 |
| Rate for Payer: Aetna of NY Medicare |
$9.20
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$8.00
|
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: CDPHP Medicare |
$7.40
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$16.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$16.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$16.00
|
| Rate for Payer: EmblemHealth Medicaid |
$16.00
|
| Rate for Payer: EmblemHealth Medicare |
$6.80
|
| Rate for Payer: EmblemHealth Select Care |
$14.40
|
| Rate for Payer: Fidelis Medicare |
$8.00
|
| Rate for Payer: Galaxy Health Commercial |
$13.00
|
| Rate for Payer: Hamaspik Choice Medicare |
$8.00
|
| Rate for Payer: Humana Medicare |
$8.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$9.20
|
| Rate for Payer: MVP Health Care of NY Commercial |
$15.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$11.26
|
| Rate for Payer: MVP Health Care of NY Medicare |
$8.40
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$3.00
|
| Rate for Payer: United Healthcare Medicare |
$8.00
|
| Rate for Payer: WellCare Medicare |
$11.00
|
|
|
SUMATRIPTAN SUCCINATE INJ, 6 MG
|
Facility
|
OP
|
$96.31
|
|
|
Service Code
|
HCPCS J3030
|
| Hospital Charge Code |
4400729
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.45 |
| Max. Negotiated Rate |
$267.37 |
| Rate for Payer: Aetna of NY Medicare |
$44.30
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$38.52
|
| Rate for Payer: Cash Price |
$72.23
|
| Rate for Payer: Cash Price |
$72.23
|
| Rate for Payer: CDPHP Medicare |
$35.63
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$77.05
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$77.05
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$77.05
|
| Rate for Payer: EmblemHealth Medicaid |
$77.05
|
| Rate for Payer: EmblemHealth Medicare |
$32.75
|
| Rate for Payer: EmblemHealth Select Care |
$69.34
|
| Rate for Payer: Fidelis Medicare |
$38.52
|
| Rate for Payer: Galaxy Health Commercial |
$62.60
|
| Rate for Payer: Hamaspik Choice Medicare |
$38.52
|
| Rate for Payer: Humana Medicare |
$38.52
|
| Rate for Payer: Local 1199SEIU Medicare |
$44.30
|
| Rate for Payer: MVP Health Care of NY Commercial |
$72.23
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$54.22
|
| Rate for Payer: MVP Health Care of NY Medicare |
$40.45
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$267.37
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$14.45
|
| Rate for Payer: United Healthcare Commercial |
$267.37
|
| Rate for Payer: United Healthcare Medicare |
$38.52
|
| Rate for Payer: WellCare Medicare |
$52.97
|
|
|
SUMATRIPTAN SUCCINATE INJ, 6 MG
|
Facility
|
IP
|
$96.31
|
|
|
Service Code
|
HCPCS J3030
|
| Hospital Charge Code |
4400729
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$52.97 |
| Max. Negotiated Rate |
$62.60 |
| Rate for Payer: Aetna of NY Commercial |
$52.97
|
| Rate for Payer: Cash Price |
$72.23
|
| Rate for Payer: Galaxy Health Commercial |
$62.60
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$52.97
|
| Rate for Payer: WellCare Medicare |
$52.97
|
|
|
SUPER QUICK ANCHOR PLUS #212032
|
Facility
|
IP
|
$1,764.39
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4479268
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$793.98 |
| Max. Negotiated Rate |
$1,235.07 |
| Rate for Payer: Aetna of NY Commercial |
$1,235.07
|
| Rate for Payer: Cash Price |
$1,323.29
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$882.20
|
| Rate for Payer: EmblemHealth Select Care |
$882.20
|
| Rate for Payer: Galaxy Health Commercial |
$1,146.85
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,235.07
|
| Rate for Payer: Multiplan Commercial |
$793.98
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,146.85
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$1,146.85
|
| Rate for Payer: WellCare Medicare |
$970.41
|
|
|
SUPER QUICK ANCHOR PLUS #212032
|
Facility
|
OP
|
$1,764.39
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4479268
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$264.66 |
| Max. Negotiated Rate |
$1,411.51 |
| Rate for Payer: Aetna of NY Commercial |
$1,235.07
|
| Rate for Payer: Aetna of NY Medicare |
$811.62
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$705.76
|
| Rate for Payer: Cash Price |
$1,323.29
|
| Rate for Payer: CDPHP Medicare |
$652.82
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$882.20
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$1,411.51
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$1,411.51
|
| Rate for Payer: EmblemHealth Medicaid |
$1,411.51
|
| Rate for Payer: EmblemHealth Medicare |
$599.89
|
| Rate for Payer: EmblemHealth Select Care |
$882.20
|
| Rate for Payer: Fidelis Medicare |
$705.76
|
| Rate for Payer: Galaxy Health Commercial |
$1,146.85
|
| Rate for Payer: Hamaspik Choice Medicare |
$705.76
|
| Rate for Payer: Humana Medicare |
$705.76
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,235.07
|
| Rate for Payer: Local 1199SEIU Medicare |
$811.62
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,146.85
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$1,146.85
|
| Rate for Payer: MVP Health Care of NY Medicare |
$741.04
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$264.66
|
| Rate for Payer: United Healthcare Medicare |
$705.76
|
| Rate for Payer: WellCare Medicare |
$970.41
|
|
|
SUPRANE
|
Facility
|
OP
|
$6.18
|
|
|
Service Code
|
NDC 10019064664
|
| Hospital Charge Code |
4409116
|
|
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
|
|
|
SUPRANE
|
Facility
|
IP
|
$6.18
|
|
|
Service Code
|
NDC 10019064664
|
| Hospital Charge Code |
4409116
|
|
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
|
|
|
SUPRAPUBIC CATH SET 14 FR
|
Facility
|
OP
|
$373.89
|
|
|
Service Code
|
HCPCS C2627
|
| Hospital Charge Code |
4471056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$56.08 |
| Max. Negotiated Rate |
$299.11 |
| Rate for Payer: Aetna of NY Commercial |
$261.72
|
| Rate for Payer: Aetna of NY Medicare |
$171.99
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$149.56
|
| Rate for Payer: Cash Price |
$280.42
|
| Rate for Payer: CDPHP Medicare |
$138.34
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$299.11
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$299.11
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$299.11
|
| Rate for Payer: EmblemHealth Medicaid |
$299.11
|
| Rate for Payer: EmblemHealth Medicare |
$127.12
|
| Rate for Payer: EmblemHealth Select Care |
$269.20
|
| Rate for Payer: Fidelis Medicare |
$149.56
|
| Rate for Payer: Galaxy Health Commercial |
$243.03
|
| Rate for Payer: Hamaspik Choice Medicare |
$149.56
|
| Rate for Payer: Humana Medicare |
$149.56
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$261.72
|
| Rate for Payer: Local 1199SEIU Medicare |
$171.99
|
| Rate for Payer: MVP Health Care of NY Commercial |
$280.42
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$210.50
|
| Rate for Payer: MVP Health Care of NY Medicare |
$157.03
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$56.08
|
| Rate for Payer: United Healthcare Medicare |
$149.56
|
| Rate for Payer: WellCare Medicare |
$205.64
|
|
|
SUPRAPUBIC CATH SET 14 FR
|
Facility
|
IP
|
$373.89
|
|
|
Service Code
|
HCPCS C2627
|
| Hospital Charge Code |
4471056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$243.03 |
| Max. Negotiated Rate |
$243.03 |
| Rate for Payer: Cash Price |
$280.42
|
| Rate for Payer: Galaxy Health Commercial |
$243.03
|
|
|
SURGIPRO 4/0 18IN BLUE FS-2 C-
|
Facility
|
IP
|
$35.02
|
|
| Hospital Charge Code |
4472083
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$22.76 |
| Max. Negotiated Rate |
$22.76 |
| Rate for Payer: Cash Price |
$26.26
|
| Rate for Payer: Galaxy Health Commercial |
$22.76
|
|
|
SURGIPRO 4/0 18IN BLUE FS-2 C-
|
Facility
|
OP
|
$35.02
|
|
| Hospital Charge Code |
4472083
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$5.25 |
| Max. Negotiated Rate |
$28.02 |
| Rate for Payer: Aetna of NY Commercial |
$24.51
|
| Rate for Payer: Aetna of NY Medicare |
$16.11
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$14.01
|
| Rate for Payer: Cash Price |
$26.26
|
| Rate for Payer: CDPHP Medicare |
$12.96
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$28.02
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$28.02
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$28.02
|
| Rate for Payer: EmblemHealth Medicaid |
$28.02
|
| Rate for Payer: EmblemHealth Medicare |
$11.91
|
| Rate for Payer: EmblemHealth Select Care |
$25.21
|
| Rate for Payer: Fidelis Medicare |
$14.01
|
| Rate for Payer: Galaxy Health Commercial |
$22.76
|
| Rate for Payer: Hamaspik Choice Medicare |
$14.01
|
| Rate for Payer: Humana Medicare |
$14.01
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$24.51
|
| Rate for Payer: Local 1199SEIU Medicare |
$16.11
|
| Rate for Payer: MVP Health Care of NY Commercial |
$26.27
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$19.72
|
| Rate for Payer: MVP Health Care of NY Medicare |
$14.71
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$5.25
|
| Rate for Payer: United Healthcare Medicare |
$14.01
|
| Rate for Payer: WellCare Medicare |
$19.26
|
|
|
SURG PATH LVL 2
|
Facility
|
OP
|
$118.00
|
|
|
Service Code
|
HCPCS 88302 TC
|
| Hospital Charge Code |
4008302
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$17.70 |
| Max. Negotiated Rate |
$94.40 |
| Rate for Payer: Aetna of NY Commercial |
$76.70
|
| Rate for Payer: Aetna of NY Medicare |
$54.28
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$47.20
|
| Rate for Payer: Cash Price |
$88.50
|
| Rate for Payer: CDPHP Medicare |
$43.66
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$70.80
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$94.40
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$94.40
|
| Rate for Payer: EmblemHealth Medicaid |
$94.40
|
| Rate for Payer: EmblemHealth Medicare |
$40.12
|
| Rate for Payer: EmblemHealth Select Care |
$70.80
|
| Rate for Payer: Fidelis Medicare |
$47.20
|
| Rate for Payer: Galaxy Health Commercial |
$76.70
|
| Rate for Payer: Hamaspik Choice Medicare |
$47.20
|
| Rate for Payer: Humana Medicare |
$47.20
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$76.70
|
| Rate for Payer: Local 1199SEIU Medicare |
$54.28
|
| Rate for Payer: MVP Health Care of NY Commercial |
$88.50
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$66.43
|
| Rate for Payer: MVP Health Care of NY Medicare |
$49.56
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$88.50
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$17.70
|
| Rate for Payer: United Healthcare Commercial |
$88.50
|
| Rate for Payer: United Healthcare Medicare |
$47.20
|
| Rate for Payer: WellCare Medicare |
$64.90
|
|
|
SURG PATH LVL 2
|
Facility
|
IP
|
$118.00
|
|
|
Service Code
|
HCPCS 88302 TC
|
| Hospital Charge Code |
4008302
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$76.70 |
| Max. Negotiated Rate |
$76.70 |
| Rate for Payer: Cash Price |
$88.50
|
| Rate for Payer: Galaxy Health Commercial |
$76.70
|
|
|
SUTURE ETHILON 6/0 18IN BLAC
|
Facility
|
IP
|
$37.08
|
|
| Hospital Charge Code |
4471170
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$24.10 |
| Max. Negotiated Rate |
$24.10 |
| Rate for Payer: Cash Price |
$27.81
|
| Rate for Payer: Galaxy Health Commercial |
$24.10
|
|
|
SUTURE ETHILON 6/0 18IN BLAC
|
Facility
|
OP
|
$37.08
|
|
| Hospital Charge Code |
4471170
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$5.56 |
| Max. Negotiated Rate |
$29.66 |
| Rate for Payer: Aetna of NY Commercial |
$25.96
|
| Rate for Payer: Aetna of NY Medicare |
$17.06
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$14.83
|
| Rate for Payer: Cash Price |
$27.81
|
| Rate for Payer: CDPHP Medicare |
$13.72
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$29.66
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$29.66
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$29.66
|
| Rate for Payer: EmblemHealth Medicaid |
$29.66
|
| Rate for Payer: EmblemHealth Medicare |
$12.61
|
| Rate for Payer: EmblemHealth Select Care |
$26.70
|
| Rate for Payer: Fidelis Medicare |
$14.83
|
| Rate for Payer: Galaxy Health Commercial |
$24.10
|
| Rate for Payer: Hamaspik Choice Medicare |
$14.83
|
| Rate for Payer: Humana Medicare |
$14.83
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$25.96
|
| Rate for Payer: Local 1199SEIU Medicare |
$17.06
|
| Rate for Payer: MVP Health Care of NY Commercial |
$27.81
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$20.88
|
| Rate for Payer: MVP Health Care of NY Medicare |
$15.57
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$5.56
|
| Rate for Payer: United Healthcare Medicare |
$14.83
|
| Rate for Payer: WellCare Medicare |
$20.39
|
|
