|
THERASKIN PER 1 SQ CM (102TSL)
|
Facility
|
IP
|
$381.00
|
|
|
Service Code
|
HCPCS Q4121
|
| Hospital Charge Code |
4473007
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$171.45 |
| Max. Negotiated Rate |
$266.70 |
| Rate for Payer: Aetna of NY Commercial |
$266.70
|
| Rate for Payer: Cash Price |
$285.75
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$190.50
|
| Rate for Payer: EmblemHealth Select Care |
$190.50
|
| Rate for Payer: Galaxy Health Commercial |
$247.65
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$266.70
|
| Rate for Payer: Multiplan Commercial |
$171.45
|
| Rate for Payer: MVP Health Care of NY Commercial |
$247.65
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$247.65
|
| Rate for Payer: WellCare Medicare |
$209.55
|
|
|
THERASKIN PER 1 SQ CM (102TSL)
|
Facility
|
OP
|
$381.00
|
|
|
Service Code
|
HCPCS Q4121
|
| Hospital Charge Code |
4473007
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$57.15 |
| Max. Negotiated Rate |
$304.80 |
| Rate for Payer: Aetna of NY Commercial |
$266.70
|
| Rate for Payer: Aetna of NY Medicare |
$175.26
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$152.40
|
| Rate for Payer: Cash Price |
$285.75
|
| Rate for Payer: CDPHP Medicare |
$140.97
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$190.50
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$304.80
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$304.80
|
| Rate for Payer: EmblemHealth Medicaid |
$304.80
|
| Rate for Payer: EmblemHealth Medicare |
$129.54
|
| Rate for Payer: EmblemHealth Select Care |
$190.50
|
| Rate for Payer: Fidelis Medicare |
$152.40
|
| Rate for Payer: Galaxy Health Commercial |
$247.65
|
| Rate for Payer: Hamaspik Choice Medicare |
$152.40
|
| Rate for Payer: Humana Medicare |
$152.40
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$266.70
|
| Rate for Payer: Local 1199SEIU Medicare |
$175.26
|
| Rate for Payer: MVP Health Care of NY Commercial |
$247.65
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$247.65
|
| Rate for Payer: MVP Health Care of NY Medicare |
$160.02
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$57.15
|
| Rate for Payer: United Healthcare Medicare |
$152.40
|
| Rate for Payer: WellCare Medicare |
$209.55
|
|
|
THERA TABLET 1 ea, 100 eaches
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
NDC 904053961
|
| Hospital Charge Code |
4401350
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.90 |
| Max. Negotiated Rate |
$4.80 |
| Rate for Payer: Aetna of NY Commercial |
$4.20
|
| 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 Aetna Signature Administrators |
$4.20
|
| 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
|
|
|
THERA TABLET 1 ea, 100 eaches
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
NDC 904053961
|
| Hospital Charge Code |
4401350
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.30 |
| Max. Negotiated Rate |
$3.90 |
| Rate for Payer: Cash Price |
$4.50
|
| Rate for Payer: Galaxy Health Commercial |
$3.90
|
| Rate for Payer: WellCare Medicare |
$3.30
|
|
|
THER/DIAG CONCURRENT INF
|
Facility
|
IP
|
$68.00
|
|
|
Service Code
|
HCPCS 96368
|
| Hospital Charge Code |
4451243
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$44.20 |
| Max. Negotiated Rate |
$44.20 |
| Rate for Payer: Cash Price |
$51.00
|
| Rate for Payer: Galaxy Health Commercial |
$44.20
|
|
|
THER/DIAG CONCURRENT INF
|
Facility
|
OP
|
$68.00
|
|
|
Service Code
|
HCPCS 96368
|
| Hospital Charge Code |
4451243
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$10.20 |
| Max. Negotiated Rate |
$54.40 |
| Rate for Payer: Aetna of NY Commercial |
$47.60
|
| Rate for Payer: Aetna of NY Medicare |
$31.28
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$27.20
|
| Rate for Payer: Cash Price |
$51.00
|
| Rate for Payer: CDPHP Medicare |
$25.16
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$54.40
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$54.40
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$54.40
|
| Rate for Payer: EmblemHealth Medicaid |
$54.40
|
| Rate for Payer: EmblemHealth Medicare |
$23.12
|
| Rate for Payer: EmblemHealth Select Care |
$48.96
|
| Rate for Payer: Fidelis Medicare |
$27.20
|
| Rate for Payer: Galaxy Health Commercial |
$44.20
|
| Rate for Payer: Hamaspik Choice Medicare |
$27.20
|
| Rate for Payer: Humana Medicare |
$27.20
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$47.60
|
| Rate for Payer: Local 1199SEIU Medicare |
$31.28
|
| Rate for Payer: MVP Health Care of NY Commercial |
$51.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$38.28
|
| Rate for Payer: MVP Health Care of NY Medicare |
$28.56
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$51.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$10.20
|
| Rate for Payer: United Healthcare Commercial |
$51.00
|
| Rate for Payer: United Healthcare Medicare |
$27.20
|
| Rate for Payer: WellCare Medicare |
$37.40
|
|
|
THER INT COG FUNC 1ST 15 MIN
|
Facility
|
OP
|
$87.00
|
|
|
Service Code
|
HCPCS 97129 GO
|
| Hospital Charge Code |
4690199
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$13.05 |
| Max. Negotiated Rate |
$187.00 |
| Rate for Payer: Aetna of NY Commercial |
$115.00
|
| Rate for Payer: Aetna of NY Medicare |
$40.02
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$34.80
|
| Rate for Payer: Cash Price |
$65.25
|
| Rate for Payer: Cash Price |
$65.25
|
| Rate for Payer: Cash Price |
$65.25
|
| Rate for Payer: CDPHP Medicare |
$32.19
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$69.60
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$56.50
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$47.08
|
| Rate for Payer: EmblemHealth Medicaid |
$47.08
|
| Rate for Payer: EmblemHealth Medicare |
$29.58
|
| Rate for Payer: EmblemHealth Select Care |
$62.64
|
| Rate for Payer: Fidelis Medicare |
$34.80
|
| Rate for Payer: Galaxy Health Commercial |
$56.55
|
| Rate for Payer: Galaxy Health Workers Comp |
$46.14
|
| Rate for Payer: Hamaspik Choice Medicaid |
$47.08
|
| Rate for Payer: Hamaspik Choice Medicare |
$34.80
|
| Rate for Payer: Humana Medicare |
$34.80
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$115.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$40.02
|
| Rate for Payer: MVP Health Care of NY Child Health Plus/Family Health Plus/HARP/Medicaid |
$49.43
|
| Rate for Payer: MVP Health Care of NY Commercial |
$187.00
|
| Rate for Payer: MVP Health Care of NY Essential Plan 1&2 |
$101.22
|
| Rate for Payer: MVP Health Care of NY Essential Plan 3&4 |
$101.22
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$141.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$36.54
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$161.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$13.05
|
| Rate for Payer: United Healthcare Commercial |
$161.00
|
| Rate for Payer: United Healthcare Medicare |
$34.80
|
| Rate for Payer: WellCare Child Health Plus/Family Health Plus/Medicaid |
$49.43
|
| Rate for Payer: WellCare Medicare |
$47.85
|
|
|
THER INT COG FUNC 1ST 15 MIN
|
Facility
|
OP
|
$87.00
|
|
|
Service Code
|
HCPCS 97129
|
| Hospital Charge Code |
4670281
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$13.05 |
| Max. Negotiated Rate |
$187.00 |
| Rate for Payer: Aetna of NY Commercial |
$115.00
|
| Rate for Payer: Aetna of NY Medicare |
$40.02
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$34.80
|
| Rate for Payer: Cash Price |
$65.25
|
| Rate for Payer: Cash Price |
$65.25
|
| Rate for Payer: Cash Price |
$65.25
|
| Rate for Payer: CDPHP Medicare |
$32.19
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$69.60
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$56.50
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$47.08
|
| Rate for Payer: EmblemHealth Medicaid |
$47.08
|
| Rate for Payer: EmblemHealth Medicare |
$29.58
|
| Rate for Payer: EmblemHealth Select Care |
$62.64
|
| Rate for Payer: Fidelis Medicare |
$34.80
|
| Rate for Payer: Galaxy Health Commercial |
$56.55
|
| Rate for Payer: Galaxy Health Workers Comp |
$46.14
|
| Rate for Payer: Hamaspik Choice Medicaid |
$47.08
|
| Rate for Payer: Hamaspik Choice Medicare |
$34.80
|
| Rate for Payer: Humana Medicare |
$34.80
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$115.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$40.02
|
| Rate for Payer: MVP Health Care of NY Child Health Plus/Family Health Plus/HARP/Medicaid |
$49.43
|
| Rate for Payer: MVP Health Care of NY Commercial |
$187.00
|
| Rate for Payer: MVP Health Care of NY Essential Plan 1&2 |
$101.22
|
| Rate for Payer: MVP Health Care of NY Essential Plan 3&4 |
$101.22
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$141.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$36.54
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$161.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$13.05
|
| Rate for Payer: United Healthcare Commercial |
$161.00
|
| Rate for Payer: United Healthcare Medicare |
$34.80
|
| Rate for Payer: WellCare Child Health Plus/Family Health Plus/Medicaid |
$49.43
|
| Rate for Payer: WellCare Medicare |
$47.85
|
|
|
THER INT COG FUNC 1ST 15 MIN
|
Facility
|
IP
|
$87.00
|
|
|
Service Code
|
HCPCS 97129 GO
|
| Hospital Charge Code |
4690199
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$56.55 |
| Max. Negotiated Rate |
$56.55 |
| Rate for Payer: Cash Price |
$65.25
|
| Rate for Payer: Galaxy Health Commercial |
$56.55
|
|
|
THER INT COG FUNC 1ST 15 MIN
|
Facility
|
IP
|
$87.00
|
|
|
Service Code
|
HCPCS 97129 GN
|
| Hospital Charge Code |
4670277
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$56.55 |
| Max. Negotiated Rate |
$56.55 |
| Rate for Payer: Cash Price |
$65.25
|
| Rate for Payer: Galaxy Health Commercial |
$56.55
|
|
|
THER INT COG FUNC 1ST 15 MIN
|
Facility
|
OP
|
$87.00
|
|
|
Service Code
|
HCPCS 97129 GN
|
| Hospital Charge Code |
4670277
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$13.05 |
| Max. Negotiated Rate |
$187.00 |
| Rate for Payer: Aetna of NY Commercial |
$115.00
|
| Rate for Payer: Aetna of NY Medicare |
$40.02
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$34.80
|
| Rate for Payer: Cash Price |
$65.25
|
| Rate for Payer: Cash Price |
$65.25
|
| Rate for Payer: Cash Price |
$65.25
|
| Rate for Payer: CDPHP Medicare |
$32.19
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$69.60
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$56.50
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$47.08
|
| Rate for Payer: EmblemHealth Medicaid |
$47.08
|
| Rate for Payer: EmblemHealth Medicare |
$29.58
|
| Rate for Payer: EmblemHealth Select Care |
$62.64
|
| Rate for Payer: Fidelis Medicare |
$34.80
|
| Rate for Payer: Galaxy Health Commercial |
$56.55
|
| Rate for Payer: Galaxy Health Workers Comp |
$46.14
|
| Rate for Payer: Hamaspik Choice Medicaid |
$47.08
|
| Rate for Payer: Hamaspik Choice Medicare |
$34.80
|
| Rate for Payer: Humana Medicare |
$34.80
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$115.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$40.02
|
| Rate for Payer: MVP Health Care of NY Child Health Plus/Family Health Plus/HARP/Medicaid |
$49.43
|
| Rate for Payer: MVP Health Care of NY Commercial |
$187.00
|
| Rate for Payer: MVP Health Care of NY Essential Plan 1&2 |
$101.22
|
| Rate for Payer: MVP Health Care of NY Essential Plan 3&4 |
$101.22
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$141.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$36.54
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$161.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$13.05
|
| Rate for Payer: United Healthcare Commercial |
$161.00
|
| Rate for Payer: United Healthcare Medicare |
$34.80
|
| Rate for Payer: WellCare Child Health Plus/Family Health Plus/Medicaid |
$49.43
|
| Rate for Payer: WellCare Medicare |
$47.85
|
|
|
THER INT COG FUNC 1ST 15 MIN
|
Facility
|
IP
|
$87.00
|
|
|
Service Code
|
HCPCS 97129
|
| Hospital Charge Code |
4670281
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$56.55 |
| Max. Negotiated Rate |
$56.55 |
| Rate for Payer: Cash Price |
$65.25
|
| Rate for Payer: Galaxy Health Commercial |
$56.55
|
|
|
THER INT COG FUNC 1ST 15 MIN (W/ KX)
|
Facility
|
OP
|
$87.00
|
|
|
Service Code
|
HCPCS 97129 GN,KX
|
| Hospital Charge Code |
4670279
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$13.05 |
| Max. Negotiated Rate |
$187.00 |
| Rate for Payer: Aetna of NY Commercial |
$115.00
|
| Rate for Payer: Aetna of NY Medicare |
$40.02
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$34.80
|
| Rate for Payer: Cash Price |
$65.25
|
| Rate for Payer: Cash Price |
$65.25
|
| Rate for Payer: Cash Price |
$65.25
|
| Rate for Payer: CDPHP Medicare |
$32.19
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$69.60
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$56.50
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$47.08
|
| Rate for Payer: EmblemHealth Medicaid |
$47.08
|
| Rate for Payer: EmblemHealth Medicare |
$29.58
|
| Rate for Payer: EmblemHealth Select Care |
$62.64
|
| Rate for Payer: Fidelis Medicare |
$34.80
|
| Rate for Payer: Galaxy Health Commercial |
$56.55
|
| Rate for Payer: Galaxy Health Workers Comp |
$46.14
|
| Rate for Payer: Hamaspik Choice Medicaid |
$47.08
|
| Rate for Payer: Hamaspik Choice Medicare |
$34.80
|
| Rate for Payer: Humana Medicare |
$34.80
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$115.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$40.02
|
| Rate for Payer: MVP Health Care of NY Child Health Plus/Family Health Plus/HARP/Medicaid |
$49.43
|
| Rate for Payer: MVP Health Care of NY Commercial |
$187.00
|
| Rate for Payer: MVP Health Care of NY Essential Plan 1&2 |
$101.22
|
| Rate for Payer: MVP Health Care of NY Essential Plan 3&4 |
$101.22
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$141.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$36.54
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$161.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$13.05
|
| Rate for Payer: United Healthcare Commercial |
$161.00
|
| Rate for Payer: United Healthcare Medicare |
$34.80
|
| Rate for Payer: WellCare Child Health Plus/Family Health Plus/Medicaid |
$49.43
|
| Rate for Payer: WellCare Medicare |
$47.85
|
|
|
THER INT COG FUNC 1ST 15 MIN (W/ KX)
|
Facility
|
OP
|
$87.00
|
|
|
Service Code
|
HCPCS 97129 GO,KX
|
| Hospital Charge Code |
4690201
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$13.05 |
| Max. Negotiated Rate |
$187.00 |
| Rate for Payer: Aetna of NY Commercial |
$115.00
|
| Rate for Payer: Aetna of NY Medicare |
$40.02
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$34.80
|
| Rate for Payer: Cash Price |
$65.25
|
| Rate for Payer: Cash Price |
$65.25
|
| Rate for Payer: Cash Price |
$65.25
|
| Rate for Payer: CDPHP Medicare |
$32.19
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$69.60
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$56.50
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$47.08
|
| Rate for Payer: EmblemHealth Medicaid |
$47.08
|
| Rate for Payer: EmblemHealth Medicare |
$29.58
|
| Rate for Payer: EmblemHealth Select Care |
$62.64
|
| Rate for Payer: Fidelis Medicare |
$34.80
|
| Rate for Payer: Galaxy Health Commercial |
$56.55
|
| Rate for Payer: Galaxy Health Workers Comp |
$46.14
|
| Rate for Payer: Hamaspik Choice Medicaid |
$47.08
|
| Rate for Payer: Hamaspik Choice Medicare |
$34.80
|
| Rate for Payer: Humana Medicare |
$34.80
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$115.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$40.02
|
| Rate for Payer: MVP Health Care of NY Child Health Plus/Family Health Plus/HARP/Medicaid |
$49.43
|
| Rate for Payer: MVP Health Care of NY Commercial |
$187.00
|
| Rate for Payer: MVP Health Care of NY Essential Plan 1&2 |
$101.22
|
| Rate for Payer: MVP Health Care of NY Essential Plan 3&4 |
$101.22
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$141.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$36.54
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$161.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$13.05
|
| Rate for Payer: United Healthcare Commercial |
$161.00
|
| Rate for Payer: United Healthcare Medicare |
$34.80
|
| Rate for Payer: WellCare Child Health Plus/Family Health Plus/Medicaid |
$49.43
|
| Rate for Payer: WellCare Medicare |
$47.85
|
|
|
THER INT COG FUNC 1ST 15 MIN (W/ KX)
|
Facility
|
IP
|
$87.00
|
|
|
Service Code
|
HCPCS 97129 GN,KX
|
| Hospital Charge Code |
4670279
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$56.55 |
| Max. Negotiated Rate |
$56.55 |
| Rate for Payer: Cash Price |
$65.25
|
| Rate for Payer: Galaxy Health Commercial |
$56.55
|
|
|
THER INT COG FUNC 1ST 15 MIN (W/ KX)
|
Facility
|
IP
|
$87.00
|
|
|
Service Code
|
HCPCS 97129 GO,KX
|
| Hospital Charge Code |
4690201
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$56.55 |
| Max. Negotiated Rate |
$56.55 |
| Rate for Payer: Cash Price |
$65.25
|
| Rate for Payer: Galaxy Health Commercial |
$56.55
|
|
|
THER INT COG FUNC EA ADD 15 MIN
|
Facility
|
IP
|
$83.00
|
|
|
Service Code
|
HCPCS 97130 GN
|
| Hospital Charge Code |
4670278
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$53.95 |
| Max. Negotiated Rate |
$53.95 |
| Rate for Payer: Cash Price |
$62.25
|
| Rate for Payer: Galaxy Health Commercial |
$53.95
|
|
|
THER INT COG FUNC EA ADD 15 MIN
|
Facility
|
OP
|
$83.00
|
|
|
Service Code
|
HCPCS 97130
|
| Hospital Charge Code |
4670282
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$12.45 |
| Max. Negotiated Rate |
$187.00 |
| Rate for Payer: Aetna of NY Commercial |
$115.00
|
| Rate for Payer: Aetna of NY Medicare |
$38.18
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$33.20
|
| Rate for Payer: Cash Price |
$62.25
|
| Rate for Payer: Cash Price |
$62.25
|
| Rate for Payer: Cash Price |
$62.25
|
| Rate for Payer: CDPHP Medicare |
$30.71
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$66.40
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$56.50
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$47.08
|
| Rate for Payer: EmblemHealth Medicaid |
$47.08
|
| Rate for Payer: EmblemHealth Medicare |
$28.22
|
| Rate for Payer: EmblemHealth Select Care |
$59.76
|
| Rate for Payer: Fidelis Medicare |
$33.20
|
| Rate for Payer: Galaxy Health Commercial |
$53.95
|
| Rate for Payer: Galaxy Health Workers Comp |
$46.14
|
| Rate for Payer: Hamaspik Choice Medicaid |
$47.08
|
| Rate for Payer: Hamaspik Choice Medicare |
$33.20
|
| Rate for Payer: Humana Medicare |
$33.20
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$115.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$38.18
|
| Rate for Payer: MVP Health Care of NY Child Health Plus/Family Health Plus/HARP/Medicaid |
$49.43
|
| Rate for Payer: MVP Health Care of NY Commercial |
$187.00
|
| Rate for Payer: MVP Health Care of NY Essential Plan 1&2 |
$101.22
|
| Rate for Payer: MVP Health Care of NY Essential Plan 3&4 |
$101.22
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$141.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$34.86
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$161.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$12.45
|
| Rate for Payer: United Healthcare Commercial |
$161.00
|
| Rate for Payer: United Healthcare Medicare |
$33.20
|
| Rate for Payer: WellCare Child Health Plus/Family Health Plus/Medicaid |
$49.43
|
| Rate for Payer: WellCare Medicare |
$45.65
|
|
|
THER INT COG FUNC EA ADD 15 MIN
|
Facility
|
IP
|
$83.00
|
|
|
Service Code
|
HCPCS 97130
|
| Hospital Charge Code |
4670282
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$53.95 |
| Max. Negotiated Rate |
$53.95 |
| Rate for Payer: Cash Price |
$62.25
|
| Rate for Payer: Galaxy Health Commercial |
$53.95
|
|
|
THER INT COG FUNC EA ADD 15 MIN
|
Facility
|
OP
|
$83.00
|
|
|
Service Code
|
HCPCS 97130 GN
|
| Hospital Charge Code |
4670278
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$12.45 |
| Max. Negotiated Rate |
$187.00 |
| Rate for Payer: Aetna of NY Commercial |
$115.00
|
| Rate for Payer: Aetna of NY Medicare |
$38.18
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$33.20
|
| Rate for Payer: Cash Price |
$62.25
|
| Rate for Payer: Cash Price |
$62.25
|
| Rate for Payer: Cash Price |
$62.25
|
| Rate for Payer: CDPHP Medicare |
$30.71
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$66.40
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$56.50
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$47.08
|
| Rate for Payer: EmblemHealth Medicaid |
$47.08
|
| Rate for Payer: EmblemHealth Medicare |
$28.22
|
| Rate for Payer: EmblemHealth Select Care |
$59.76
|
| Rate for Payer: Fidelis Medicare |
$33.20
|
| Rate for Payer: Galaxy Health Commercial |
$53.95
|
| Rate for Payer: Galaxy Health Workers Comp |
$46.14
|
| Rate for Payer: Hamaspik Choice Medicaid |
$47.08
|
| Rate for Payer: Hamaspik Choice Medicare |
$33.20
|
| Rate for Payer: Humana Medicare |
$33.20
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$115.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$38.18
|
| Rate for Payer: MVP Health Care of NY Child Health Plus/Family Health Plus/HARP/Medicaid |
$49.43
|
| Rate for Payer: MVP Health Care of NY Commercial |
$187.00
|
| Rate for Payer: MVP Health Care of NY Essential Plan 1&2 |
$101.22
|
| Rate for Payer: MVP Health Care of NY Essential Plan 3&4 |
$101.22
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$141.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$34.86
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$161.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$12.45
|
| Rate for Payer: United Healthcare Commercial |
$161.00
|
| Rate for Payer: United Healthcare Medicare |
$33.20
|
| Rate for Payer: WellCare Child Health Plus/Family Health Plus/Medicaid |
$49.43
|
| Rate for Payer: WellCare Medicare |
$45.65
|
|
|
THER INT COG FUNC EA ADD 15 MIN
|
Facility
|
OP
|
$83.00
|
|
|
Service Code
|
HCPCS 97130 GO
|
| Hospital Charge Code |
4690200
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$12.45 |
| Max. Negotiated Rate |
$187.00 |
| Rate for Payer: Aetna of NY Commercial |
$115.00
|
| Rate for Payer: Aetna of NY Medicare |
$38.18
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$33.20
|
| Rate for Payer: Cash Price |
$62.25
|
| Rate for Payer: Cash Price |
$62.25
|
| Rate for Payer: Cash Price |
$62.25
|
| Rate for Payer: CDPHP Medicare |
$30.71
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$66.40
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$56.50
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$47.08
|
| Rate for Payer: EmblemHealth Medicaid |
$47.08
|
| Rate for Payer: EmblemHealth Medicare |
$28.22
|
| Rate for Payer: EmblemHealth Select Care |
$59.76
|
| Rate for Payer: Fidelis Medicare |
$33.20
|
| Rate for Payer: Galaxy Health Commercial |
$53.95
|
| Rate for Payer: Galaxy Health Workers Comp |
$46.14
|
| Rate for Payer: Hamaspik Choice Medicaid |
$47.08
|
| Rate for Payer: Hamaspik Choice Medicare |
$33.20
|
| Rate for Payer: Humana Medicare |
$33.20
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$115.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$38.18
|
| Rate for Payer: MVP Health Care of NY Child Health Plus/Family Health Plus/HARP/Medicaid |
$49.43
|
| Rate for Payer: MVP Health Care of NY Commercial |
$187.00
|
| Rate for Payer: MVP Health Care of NY Essential Plan 1&2 |
$101.22
|
| Rate for Payer: MVP Health Care of NY Essential Plan 3&4 |
$101.22
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$141.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$34.86
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$161.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$12.45
|
| Rate for Payer: United Healthcare Commercial |
$161.00
|
| Rate for Payer: United Healthcare Medicare |
$33.20
|
| Rate for Payer: WellCare Child Health Plus/Family Health Plus/Medicaid |
$49.43
|
| Rate for Payer: WellCare Medicare |
$45.65
|
|
|
THER INT COG FUNC EA ADD 15 MIN
|
Facility
|
IP
|
$83.00
|
|
|
Service Code
|
HCPCS 97130 GO
|
| Hospital Charge Code |
4690200
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$53.95 |
| Max. Negotiated Rate |
$53.95 |
| Rate for Payer: Cash Price |
$62.25
|
| Rate for Payer: Galaxy Health Commercial |
$53.95
|
|
|
THER INT COG FUNC EA ADD 15 MIN (W/ KX)
|
Facility
|
IP
|
$83.00
|
|
|
Service Code
|
HCPCS 97130 GN,KX
|
| Hospital Charge Code |
4670280
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$53.95 |
| Max. Negotiated Rate |
$53.95 |
| Rate for Payer: Cash Price |
$62.25
|
| Rate for Payer: Galaxy Health Commercial |
$53.95
|
|
|
THER INT COG FUNC EA ADD 15 MIN (W/ KX)
|
Facility
|
OP
|
$83.00
|
|
|
Service Code
|
HCPCS 97130 GO,KX
|
| Hospital Charge Code |
4690202
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$12.45 |
| Max. Negotiated Rate |
$187.00 |
| Rate for Payer: Aetna of NY Commercial |
$115.00
|
| Rate for Payer: Aetna of NY Medicare |
$38.18
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$33.20
|
| Rate for Payer: Cash Price |
$62.25
|
| Rate for Payer: Cash Price |
$62.25
|
| Rate for Payer: Cash Price |
$62.25
|
| Rate for Payer: CDPHP Medicare |
$30.71
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$66.40
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$56.50
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$47.08
|
| Rate for Payer: EmblemHealth Medicaid |
$47.08
|
| Rate for Payer: EmblemHealth Medicare |
$28.22
|
| Rate for Payer: EmblemHealth Select Care |
$59.76
|
| Rate for Payer: Fidelis Medicare |
$33.20
|
| Rate for Payer: Galaxy Health Commercial |
$53.95
|
| Rate for Payer: Galaxy Health Workers Comp |
$46.14
|
| Rate for Payer: Hamaspik Choice Medicaid |
$47.08
|
| Rate for Payer: Hamaspik Choice Medicare |
$33.20
|
| Rate for Payer: Humana Medicare |
$33.20
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$115.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$38.18
|
| Rate for Payer: MVP Health Care of NY Child Health Plus/Family Health Plus/HARP/Medicaid |
$49.43
|
| Rate for Payer: MVP Health Care of NY Commercial |
$187.00
|
| Rate for Payer: MVP Health Care of NY Essential Plan 1&2 |
$101.22
|
| Rate for Payer: MVP Health Care of NY Essential Plan 3&4 |
$101.22
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$141.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$34.86
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$161.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$12.45
|
| Rate for Payer: United Healthcare Commercial |
$161.00
|
| Rate for Payer: United Healthcare Medicare |
$33.20
|
| Rate for Payer: WellCare Child Health Plus/Family Health Plus/Medicaid |
$49.43
|
| Rate for Payer: WellCare Medicare |
$45.65
|
|
|
THER INT COG FUNC EA ADD 15 MIN (W/ KX)
|
Facility
|
IP
|
$83.00
|
|
|
Service Code
|
HCPCS 97130 GO,KX
|
| Hospital Charge Code |
4690202
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$53.95 |
| Max. Negotiated Rate |
$53.95 |
| Rate for Payer: Cash Price |
$62.25
|
| Rate for Payer: Galaxy Health Commercial |
$53.95
|
|
