|
TOMOSYNTHESIS, MAMMO, RIGHT
|
Facility
|
IP
|
$194.00
|
|
|
Service Code
|
HCPCS G0279 RT,TC
|
| Hospital Charge Code |
4150411
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$126.10 |
| Max. Negotiated Rate |
$126.10 |
| Rate for Payer: Cash Price |
$145.50
|
| Rate for Payer: Galaxy Health Commercial |
$126.10
|
|
|
TOMOSYNTHESIS, MAMMO, RIGHT
|
Facility
|
OP
|
$89.00
|
|
|
Service Code
|
HCPCS G0279 26,RT
|
| Hospital Charge Code |
5150411
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$13.35 |
| Max. Negotiated Rate |
$71.20 |
| Rate for Payer: Aetna of NY Commercial |
$62.30
|
| Rate for Payer: Aetna of NY Medicare |
$40.94
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$35.60
|
| Rate for Payer: Cash Price |
$66.75
|
| Rate for Payer: CDPHP Medicare |
$32.93
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$71.20
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$71.20
|
| Rate for Payer: EmblemHealth Medicaid |
$71.20
|
| Rate for Payer: EmblemHealth Medicare |
$30.26
|
| Rate for Payer: Fidelis Medicare |
$35.60
|
| Rate for Payer: Galaxy Health Commercial |
$57.85
|
| Rate for Payer: Hamaspik Choice Medicare |
$35.60
|
| Rate for Payer: Humana Medicare |
$35.60
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$62.30
|
| Rate for Payer: Local 1199SEIU Medicare |
$40.94
|
| Rate for Payer: MVP Health Care of NY Commercial |
$66.75
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$50.11
|
| Rate for Payer: MVP Health Care of NY Medicare |
$37.38
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$13.35
|
| Rate for Payer: United Healthcare Medicare |
$35.60
|
| Rate for Payer: WellCare Medicare |
$48.95
|
|
|
TOMOSYNTHESIS, MAMMO, RIGHT
|
Facility
|
OP
|
$194.00
|
|
|
Service Code
|
HCPCS G0279 RT,TC
|
| Hospital Charge Code |
4150411
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$29.10 |
| Max. Negotiated Rate |
$489.00 |
| Rate for Payer: Aetna of NY Commercial |
$135.80
|
| Rate for Payer: Aetna of NY Medicare |
$89.24
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$77.60
|
| Rate for Payer: Cash Price |
$145.50
|
| Rate for Payer: Cash Price |
$145.50
|
| Rate for Payer: CDPHP Medicare |
$71.78
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$135.80
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$155.20
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$155.20
|
| Rate for Payer: EmblemHealth Medicaid |
$155.20
|
| Rate for Payer: EmblemHealth Medicare |
$65.96
|
| Rate for Payer: EmblemHealth Select Care |
$126.10
|
| Rate for Payer: Fidelis Medicare |
$77.60
|
| Rate for Payer: Galaxy Health Commercial |
$126.10
|
| Rate for Payer: Hamaspik Choice Medicare |
$77.60
|
| Rate for Payer: Humana Medicare |
$77.60
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$135.80
|
| Rate for Payer: Local 1199SEIU Medicare |
$89.24
|
| Rate for Payer: MVP Health Care of NY Commercial |
$145.50
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$109.22
|
| Rate for Payer: MVP Health Care of NY Medicare |
$81.48
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$489.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$29.10
|
| Rate for Payer: United Healthcare Commercial |
$489.00
|
| Rate for Payer: United Healthcare Medicare |
$77.60
|
| Rate for Payer: WellCare Medicare |
$106.70
|
|
|
TOMOSYNTHESIS, MAMMO, RIGHT
|
Facility
|
IP
|
$89.00
|
|
|
Service Code
|
HCPCS G0279 26,RT
|
| Hospital Charge Code |
5150411
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$57.85 |
| Max. Negotiated Rate |
$57.85 |
| Rate for Payer: Cash Price |
$66.75
|
| Rate for Payer: Galaxy Health Commercial |
$57.85
|
|
|
TOPAMAX (TOPIRAMATE)
|
Facility
|
IP
|
$36.00
|
|
|
Service Code
|
HCPCS 80201
|
| Hospital Charge Code |
4301167
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$23.40 |
| Max. Negotiated Rate |
$23.40 |
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Galaxy Health Commercial |
$23.40
|
|
|
TOPAMAX (TOPIRAMATE)
|
Facility
|
OP
|
$36.00
|
|
|
Service Code
|
HCPCS 80201
|
| Hospital Charge Code |
4301167
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.40 |
| Max. Negotiated Rate |
$28.80 |
| Rate for Payer: Aetna of NY Commercial |
$23.40
|
| Rate for Payer: Aetna of NY Medicare |
$16.56
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$14.40
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: CDPHP Medicare |
$13.32
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$21.60
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$28.80
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$28.80
|
| Rate for Payer: EmblemHealth Medicaid |
$28.80
|
| Rate for Payer: EmblemHealth Medicare |
$12.24
|
| Rate for Payer: EmblemHealth Select Care |
$21.60
|
| Rate for Payer: Fidelis Medicare |
$14.40
|
| Rate for Payer: Galaxy Health Commercial |
$23.40
|
| Rate for Payer: Hamaspik Choice Medicare |
$14.40
|
| Rate for Payer: Humana Medicare |
$14.40
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$23.40
|
| Rate for Payer: Local 1199SEIU Medicare |
$16.56
|
| Rate for Payer: MVP Health Care of NY Commercial |
$27.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$20.27
|
| Rate for Payer: MVP Health Care of NY Medicare |
$15.12
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$27.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$5.40
|
| Rate for Payer: United Healthcare Commercial |
$27.00
|
| Rate for Payer: United Healthcare Medicare |
$14.40
|
| Rate for Payer: WellCare Medicare |
$19.80
|
|
|
TOPIRAMATE 25MG TABS 10X10EA
|
Facility
|
IP
|
$6.44
|
|
|
Service Code
|
NDC 68084034211
|
| Hospital Charge Code |
4400764
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.54 |
| Max. Negotiated Rate |
$4.19 |
| Rate for Payer: Cash Price |
$4.83
|
| Rate for Payer: Galaxy Health Commercial |
$4.19
|
| Rate for Payer: WellCare Medicare |
$3.54
|
|
|
TOPIRAMATE 25MG TABS 10X10EA
|
Facility
|
OP
|
$6.44
|
|
|
Service Code
|
NDC 68084034211
|
| Hospital Charge Code |
4400764
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.97 |
| Max. Negotiated Rate |
$5.15 |
| Rate for Payer: Aetna of NY Commercial |
$4.51
|
| Rate for Payer: Aetna of NY Medicare |
$2.96
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$2.58
|
| Rate for Payer: Cash Price |
$4.83
|
| Rate for Payer: CDPHP Medicare |
$2.38
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$5.15
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$5.15
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$5.15
|
| Rate for Payer: EmblemHealth Medicaid |
$5.15
|
| Rate for Payer: EmblemHealth Medicare |
$2.19
|
| Rate for Payer: EmblemHealth Select Care |
$4.64
|
| Rate for Payer: Fidelis Medicare |
$2.58
|
| Rate for Payer: Galaxy Health Commercial |
$4.19
|
| Rate for Payer: Hamaspik Choice Medicare |
$2.58
|
| Rate for Payer: Humana Medicare |
$2.58
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$4.51
|
| Rate for Payer: Local 1199SEIU Medicare |
$2.96
|
| Rate for Payer: MVP Health Care of NY Commercial |
$4.83
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$3.63
|
| Rate for Payer: MVP Health Care of NY Medicare |
$2.70
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$0.97
|
| Rate for Payer: United Healthcare Medicare |
$2.58
|
| Rate for Payer: WellCare Medicare |
$3.54
|
|
|
TORPEDO SHAVER (AR-9350TD)
|
Facility
|
IP
|
$1,515.00
|
|
| Hospital Charge Code |
4473048
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$984.75 |
| Max. Negotiated Rate |
$984.75 |
| Rate for Payer: Cash Price |
$1,136.25
|
| Rate for Payer: Galaxy Health Commercial |
$984.75
|
|
|
TORPEDO SHAVER (AR-9350TD)
|
Facility
|
OP
|
$1,515.00
|
|
| Hospital Charge Code |
4473048
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$227.25 |
| Max. Negotiated Rate |
$1,212.00 |
| Rate for Payer: Aetna of NY Commercial |
$1,060.50
|
| Rate for Payer: Aetna of NY Medicare |
$696.90
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$606.00
|
| Rate for Payer: Cash Price |
$1,136.25
|
| Rate for Payer: CDPHP Medicare |
$560.55
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$1,212.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$1,212.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$1,212.00
|
| Rate for Payer: EmblemHealth Medicaid |
$1,212.00
|
| Rate for Payer: EmblemHealth Medicare |
$515.10
|
| Rate for Payer: EmblemHealth Select Care |
$1,090.80
|
| Rate for Payer: Fidelis Medicare |
$606.00
|
| Rate for Payer: Galaxy Health Commercial |
$984.75
|
| Rate for Payer: Hamaspik Choice Medicare |
$606.00
|
| Rate for Payer: Humana Medicare |
$606.00
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,060.50
|
| Rate for Payer: Local 1199SEIU Medicare |
$696.90
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,136.25
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$852.95
|
| Rate for Payer: MVP Health Care of NY Medicare |
$636.30
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$227.25
|
| Rate for Payer: United Healthcare Medicare |
$606.00
|
| Rate for Payer: WellCare Medicare |
$833.25
|
|
|
TORSEMIDE 20 MG PO
|
Facility
|
IP
|
$6.18
|
|
|
Service Code
|
NDC 68084053901
|
| Hospital Charge Code |
4409054
|
|
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
|
|
|
TORSEMIDE 20 MG PO
|
Facility
|
OP
|
$6.18
|
|
|
Service Code
|
NDC 68084053901
|
| Hospital Charge Code |
4409054
|
|
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
|
|
|
TORSEMIDE TABLET 5 MG
|
Facility
|
IP
|
$6.18
|
|
|
Service Code
|
NDC 50268075415
|
| Hospital Charge Code |
4400842
|
|
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
|
|
|
TORSEMIDE TABLET 5 MG
|
Facility
|
OP
|
$6.18
|
|
|
Service Code
|
NDC 50268075415
|
| Hospital Charge Code |
4400842
|
|
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
|
|
|
TOTAL PROTEIN OTHER SPECIMEN
|
Facility
|
IP
|
$12.00
|
|
|
Service Code
|
HCPCS 84157
|
| Hospital Charge Code |
4300894
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$7.80 |
| Max. Negotiated Rate |
$7.80 |
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Galaxy Health Commercial |
$7.80
|
|
|
TOTAL PROTEIN OTHER SPECIMEN
|
Facility
|
OP
|
$12.00
|
|
|
Service Code
|
HCPCS 84157
|
| Hospital Charge Code |
4300894
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$1.80 |
| Max. Negotiated Rate |
$9.60 |
| Rate for Payer: Aetna of NY Commercial |
$7.80
|
| Rate for Payer: Aetna of NY Medicare |
$5.52
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$4.80
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: CDPHP Medicare |
$4.44
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$7.20
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$9.60
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$9.60
|
| Rate for Payer: EmblemHealth Medicaid |
$9.60
|
| Rate for Payer: EmblemHealth Medicare |
$4.08
|
| Rate for Payer: EmblemHealth Select Care |
$7.20
|
| Rate for Payer: Fidelis Medicare |
$4.80
|
| Rate for Payer: Galaxy Health Commercial |
$7.80
|
| Rate for Payer: Hamaspik Choice Medicare |
$4.80
|
| Rate for Payer: Humana Medicare |
$4.80
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$7.80
|
| Rate for Payer: Local 1199SEIU Medicare |
$5.52
|
| Rate for Payer: MVP Health Care of NY Commercial |
$9.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$6.76
|
| Rate for Payer: MVP Health Care of NY Medicare |
$5.04
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$9.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$1.80
|
| Rate for Payer: United Healthcare Commercial |
$9.00
|
| Rate for Payer: United Healthcare Medicare |
$4.80
|
| Rate for Payer: WellCare Medicare |
$6.60
|
|
|
TOXIN ASSAY TISSUE CULTURE
|
Facility
|
OP
|
$59.00
|
|
|
Service Code
|
HCPCS 87230
|
| Hospital Charge Code |
4301205
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$8.85 |
| Max. Negotiated Rate |
$47.20 |
| Rate for Payer: Aetna of NY Commercial |
$38.35
|
| Rate for Payer: Aetna of NY Medicare |
$27.14
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$23.60
|
| Rate for Payer: Cash Price |
$44.25
|
| Rate for Payer: CDPHP Medicare |
$21.83
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$35.40
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$47.20
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$47.20
|
| Rate for Payer: EmblemHealth Medicaid |
$47.20
|
| Rate for Payer: EmblemHealth Medicare |
$20.06
|
| Rate for Payer: EmblemHealth Select Care |
$35.40
|
| Rate for Payer: Fidelis Medicare |
$23.60
|
| Rate for Payer: Galaxy Health Commercial |
$38.35
|
| Rate for Payer: Hamaspik Choice Medicare |
$23.60
|
| Rate for Payer: Humana Medicare |
$23.60
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$38.35
|
| Rate for Payer: Local 1199SEIU Medicare |
$27.14
|
| Rate for Payer: MVP Health Care of NY Commercial |
$44.25
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$33.22
|
| Rate for Payer: MVP Health Care of NY Medicare |
$24.78
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$44.25
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$8.85
|
| Rate for Payer: United Healthcare Commercial |
$44.25
|
| Rate for Payer: United Healthcare Medicare |
$23.60
|
| Rate for Payer: WellCare Medicare |
$32.45
|
|
|
TOXIN ASSAY TISSUE CULTURE
|
Facility
|
IP
|
$59.00
|
|
|
Service Code
|
HCPCS 87230
|
| Hospital Charge Code |
4301205
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$38.35 |
| Max. Negotiated Rate |
$38.35 |
| Rate for Payer: Cash Price |
$44.25
|
| Rate for Payer: Galaxy Health Commercial |
$38.35
|
|
|
TPN, > 1 LITER, <= 2 LITER PER DAY, ALL SUPPLIES/EQUIPMENT
|
Facility
|
IP
|
$462.47
|
|
| Hospital Charge Code |
1050101
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$254.36 |
| Max. Negotiated Rate |
$300.61 |
| Rate for Payer: Cash Price |
$346.85
|
| Rate for Payer: Galaxy Health Commercial |
$300.61
|
| Rate for Payer: WellCare Medicare |
$254.36
|
|
|
TPN, > 1 LITER, <= 2 LITER PER DAY, ALL SUPPLIES/EQUIPMENT
|
Facility
|
OP
|
$462.47
|
|
| Hospital Charge Code |
1050101
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$69.37 |
| Max. Negotiated Rate |
$369.98 |
| Rate for Payer: Aetna of NY Commercial |
$323.73
|
| Rate for Payer: Aetna of NY Medicare |
$212.74
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$184.99
|
| Rate for Payer: Cash Price |
$346.85
|
| Rate for Payer: CDPHP Medicare |
$171.11
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$369.98
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$369.98
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$369.98
|
| Rate for Payer: EmblemHealth Medicaid |
$369.98
|
| Rate for Payer: EmblemHealth Medicare |
$157.24
|
| Rate for Payer: EmblemHealth Select Care |
$332.98
|
| Rate for Payer: Fidelis Medicare |
$184.99
|
| Rate for Payer: Galaxy Health Commercial |
$300.61
|
| Rate for Payer: Hamaspik Choice Medicare |
$184.99
|
| Rate for Payer: Humana Medicare |
$184.99
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$323.73
|
| Rate for Payer: Local 1199SEIU Medicare |
$212.74
|
| Rate for Payer: MVP Health Care of NY Commercial |
$346.85
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$260.37
|
| Rate for Payer: MVP Health Care of NY Medicare |
$194.24
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$69.37
|
| Rate for Payer: United Healthcare Medicare |
$184.99
|
| Rate for Payer: WellCare Medicare |
$254.36
|
|
|
TPN, > 2, <=3 LITERS PER DAY, ALL SUPPLIES/EQUIPMENT
|
Facility
|
IP
|
$493.37
|
|
| Hospital Charge Code |
1050102
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$271.35 |
| Max. Negotiated Rate |
$320.69 |
| Rate for Payer: Cash Price |
$370.03
|
| Rate for Payer: Galaxy Health Commercial |
$320.69
|
| Rate for Payer: WellCare Medicare |
$271.35
|
|
|
TPN, > 2, <=3 LITERS PER DAY, ALL SUPPLIES/EQUIPMENT
|
Facility
|
OP
|
$493.37
|
|
| Hospital Charge Code |
1050102
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$74.01 |
| Max. Negotiated Rate |
$394.70 |
| Rate for Payer: Aetna of NY Commercial |
$345.36
|
| Rate for Payer: Aetna of NY Medicare |
$226.95
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$197.35
|
| Rate for Payer: Cash Price |
$370.03
|
| Rate for Payer: CDPHP Medicare |
$182.55
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$394.70
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$394.70
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$394.70
|
| Rate for Payer: EmblemHealth Medicaid |
$394.70
|
| Rate for Payer: EmblemHealth Medicare |
$167.75
|
| Rate for Payer: EmblemHealth Select Care |
$355.23
|
| Rate for Payer: Fidelis Medicare |
$197.35
|
| Rate for Payer: Galaxy Health Commercial |
$320.69
|
| Rate for Payer: Hamaspik Choice Medicare |
$197.35
|
| Rate for Payer: Humana Medicare |
$197.35
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$345.36
|
| Rate for Payer: Local 1199SEIU Medicare |
$226.95
|
| Rate for Payer: MVP Health Care of NY Commercial |
$370.03
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$277.77
|
| Rate for Payer: MVP Health Care of NY Medicare |
$207.22
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$74.01
|
| Rate for Payer: United Healthcare Medicare |
$197.35
|
| Rate for Payer: WellCare Medicare |
$271.35
|
|
|
TPN, > 3 LITERS PER DAY, ALL SUPPLIES/EQUIPMENT
|
Facility
|
IP
|
$528.39
|
|
| Hospital Charge Code |
1050103
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$290.61 |
| Max. Negotiated Rate |
$343.45 |
| Rate for Payer: Cash Price |
$396.29
|
| Rate for Payer: Galaxy Health Commercial |
$343.45
|
| Rate for Payer: WellCare Medicare |
$290.61
|
|
|
TPN, > 3 LITERS PER DAY, ALL SUPPLIES/EQUIPMENT
|
Facility
|
OP
|
$528.39
|
|
| Hospital Charge Code |
1050103
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$79.26 |
| Max. Negotiated Rate |
$422.71 |
| Rate for Payer: Aetna of NY Commercial |
$369.87
|
| Rate for Payer: Aetna of NY Medicare |
$243.06
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$211.36
|
| Rate for Payer: Cash Price |
$396.29
|
| Rate for Payer: CDPHP Medicare |
$195.50
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$422.71
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$422.71
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$422.71
|
| Rate for Payer: EmblemHealth Medicaid |
$422.71
|
| Rate for Payer: EmblemHealth Medicare |
$179.65
|
| Rate for Payer: EmblemHealth Select Care |
$380.44
|
| Rate for Payer: Fidelis Medicare |
$211.36
|
| Rate for Payer: Galaxy Health Commercial |
$343.45
|
| Rate for Payer: Hamaspik Choice Medicare |
$211.36
|
| Rate for Payer: Humana Medicare |
$211.36
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$369.87
|
| Rate for Payer: Local 1199SEIU Medicare |
$243.06
|
| Rate for Payer: MVP Health Care of NY Commercial |
$396.29
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$297.48
|
| Rate for Payer: MVP Health Care of NY Medicare |
$221.92
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$79.26
|
| Rate for Payer: United Healthcare Medicare |
$211.36
|
| Rate for Payer: WellCare Medicare |
$290.61
|
|
|
TPN, UP TO ONE LITER PER DAY, ALL SUPPLIES/EQUIPMENT
|
Facility
|
IP
|
$425.39
|
|
| Hospital Charge Code |
1050100
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$233.96 |
| Max. Negotiated Rate |
$276.50 |
| Rate for Payer: Cash Price |
$319.04
|
| Rate for Payer: Galaxy Health Commercial |
$276.50
|
| Rate for Payer: WellCare Medicare |
$233.96
|
|
