|
WHIRLPOOL THERAPY
|
Facility
|
OP
|
$64.00
|
|
|
Service Code
|
HCPCS 97022 GP
|
| Hospital Charge Code |
4650043
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$9.60 |
| Max. Negotiated Rate |
$187.00 |
| Rate for Payer: Aetna of NY Commercial |
$115.00
|
| Rate for Payer: Aetna of NY Medicare |
$29.44
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$25.60
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: CDPHP Medicare |
$23.68
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$51.20
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$26.90
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$22.42
|
| Rate for Payer: EmblemHealth Medicaid |
$22.42
|
| Rate for Payer: EmblemHealth Medicare |
$21.76
|
| Rate for Payer: EmblemHealth Select Care |
$46.08
|
| Rate for Payer: Fidelis Medicare |
$25.60
|
| Rate for Payer: Galaxy Health Commercial |
$41.60
|
| Rate for Payer: Galaxy Health Workers Comp |
$21.97
|
| Rate for Payer: Hamaspik Choice Medicaid |
$22.42
|
| Rate for Payer: Hamaspik Choice Medicare |
$25.60
|
| Rate for Payer: Humana Medicare |
$25.60
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$115.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$29.44
|
| Rate for Payer: MVP Health Care of NY Child Health Plus/Family Health Plus/HARP/Medicaid |
$23.54
|
| Rate for Payer: MVP Health Care of NY Commercial |
$187.00
|
| Rate for Payer: MVP Health Care of NY Essential Plan 1&2 |
$48.20
|
| Rate for Payer: MVP Health Care of NY Essential Plan 3&4 |
$48.20
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$141.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$26.88
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$161.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$9.60
|
| Rate for Payer: United Healthcare Commercial |
$161.00
|
| Rate for Payer: United Healthcare Medicare |
$25.60
|
| Rate for Payer: WellCare Child Health Plus/Family Health Plus/Medicaid |
$23.54
|
| Rate for Payer: WellCare Medicare |
$35.20
|
|
|
WHIRLPOOL THERAPY
|
Facility
|
IP
|
$64.00
|
|
|
Service Code
|
HCPCS 97022 GP
|
| Hospital Charge Code |
4650043
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$41.60 |
| Max. Negotiated Rate |
$41.60 |
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Galaxy Health Commercial |
$41.60
|
|
|
WHIRLPOOL THERAPY (MOD 59)
|
Facility
|
OP
|
$64.00
|
|
|
Service Code
|
HCPCS 97022 GP,59
|
| Hospital Charge Code |
4650380
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$9.60 |
| Max. Negotiated Rate |
$187.00 |
| Rate for Payer: Aetna of NY Commercial |
$115.00
|
| Rate for Payer: Aetna of NY Medicare |
$29.44
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$25.60
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: CDPHP Medicare |
$23.68
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$51.20
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$26.90
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$22.42
|
| Rate for Payer: EmblemHealth Medicaid |
$22.42
|
| Rate for Payer: EmblemHealth Medicare |
$21.76
|
| Rate for Payer: EmblemHealth Select Care |
$46.08
|
| Rate for Payer: Fidelis Medicare |
$25.60
|
| Rate for Payer: Galaxy Health Commercial |
$41.60
|
| Rate for Payer: Galaxy Health Workers Comp |
$21.97
|
| Rate for Payer: Hamaspik Choice Medicaid |
$22.42
|
| Rate for Payer: Hamaspik Choice Medicare |
$25.60
|
| Rate for Payer: Humana Medicare |
$25.60
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$115.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$29.44
|
| Rate for Payer: MVP Health Care of NY Child Health Plus/Family Health Plus/HARP/Medicaid |
$23.54
|
| Rate for Payer: MVP Health Care of NY Commercial |
$187.00
|
| Rate for Payer: MVP Health Care of NY Essential Plan 1&2 |
$48.20
|
| Rate for Payer: MVP Health Care of NY Essential Plan 3&4 |
$48.20
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$141.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$26.88
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$161.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$9.60
|
| Rate for Payer: United Healthcare Commercial |
$161.00
|
| Rate for Payer: United Healthcare Medicare |
$25.60
|
| Rate for Payer: WellCare Child Health Plus/Family Health Plus/Medicaid |
$23.54
|
| Rate for Payer: WellCare Medicare |
$35.20
|
|
|
WHIRLPOOL THERAPY (MOD 59)
|
Facility
|
IP
|
$64.00
|
|
|
Service Code
|
HCPCS 97022 GP,59
|
| Hospital Charge Code |
4650380
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$41.60 |
| Max. Negotiated Rate |
$41.60 |
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Galaxy Health Commercial |
$41.60
|
|
|
WHIRLPOOL THERAPY (MOD 59 W KX)
|
Facility
|
IP
|
$64.00
|
|
|
Service Code
|
HCPCS 97022 GP,59,KX
|
| Hospital Charge Code |
4650432
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$41.60 |
| Max. Negotiated Rate |
$41.60 |
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Galaxy Health Commercial |
$41.60
|
|
|
WHIRLPOOL THERAPY (MOD 59 W KX)
|
Facility
|
OP
|
$64.00
|
|
|
Service Code
|
HCPCS 97022 GP,59,KX
|
| Hospital Charge Code |
4650432
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$9.60 |
| Max. Negotiated Rate |
$187.00 |
| Rate for Payer: Aetna of NY Commercial |
$115.00
|
| Rate for Payer: Aetna of NY Medicare |
$29.44
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$25.60
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: CDPHP Medicare |
$23.68
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$51.20
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$26.90
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$22.42
|
| Rate for Payer: EmblemHealth Medicaid |
$22.42
|
| Rate for Payer: EmblemHealth Medicare |
$21.76
|
| Rate for Payer: EmblemHealth Select Care |
$46.08
|
| Rate for Payer: Fidelis Medicare |
$25.60
|
| Rate for Payer: Galaxy Health Commercial |
$41.60
|
| Rate for Payer: Galaxy Health Workers Comp |
$21.97
|
| Rate for Payer: Hamaspik Choice Medicaid |
$22.42
|
| Rate for Payer: Hamaspik Choice Medicare |
$25.60
|
| Rate for Payer: Humana Medicare |
$25.60
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$115.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$29.44
|
| Rate for Payer: MVP Health Care of NY Child Health Plus/Family Health Plus/HARP/Medicaid |
$23.54
|
| Rate for Payer: MVP Health Care of NY Commercial |
$187.00
|
| Rate for Payer: MVP Health Care of NY Essential Plan 1&2 |
$48.20
|
| Rate for Payer: MVP Health Care of NY Essential Plan 3&4 |
$48.20
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$141.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$26.88
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$161.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$9.60
|
| Rate for Payer: United Healthcare Commercial |
$161.00
|
| Rate for Payer: United Healthcare Medicare |
$25.60
|
| Rate for Payer: WellCare Child Health Plus/Family Health Plus/Medicaid |
$23.54
|
| Rate for Payer: WellCare Medicare |
$35.20
|
|
|
WHIRLPOOL THERAPY (W/ KX)
|
Facility
|
OP
|
$64.00
|
|
|
Service Code
|
HCPCS 97022 GP,KX
|
| Hospital Charge Code |
4650325
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$9.60 |
| Max. Negotiated Rate |
$187.00 |
| Rate for Payer: Aetna of NY Commercial |
$115.00
|
| Rate for Payer: Aetna of NY Medicare |
$29.44
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$25.60
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: CDPHP Medicare |
$23.68
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$51.20
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$26.90
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$22.42
|
| Rate for Payer: EmblemHealth Medicaid |
$22.42
|
| Rate for Payer: EmblemHealth Medicare |
$21.76
|
| Rate for Payer: EmblemHealth Select Care |
$46.08
|
| Rate for Payer: Fidelis Medicare |
$25.60
|
| Rate for Payer: Galaxy Health Commercial |
$41.60
|
| Rate for Payer: Galaxy Health Workers Comp |
$21.97
|
| Rate for Payer: Hamaspik Choice Medicaid |
$22.42
|
| Rate for Payer: Hamaspik Choice Medicare |
$25.60
|
| Rate for Payer: Humana Medicare |
$25.60
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$115.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$29.44
|
| Rate for Payer: MVP Health Care of NY Child Health Plus/Family Health Plus/HARP/Medicaid |
$23.54
|
| Rate for Payer: MVP Health Care of NY Commercial |
$187.00
|
| Rate for Payer: MVP Health Care of NY Essential Plan 1&2 |
$48.20
|
| Rate for Payer: MVP Health Care of NY Essential Plan 3&4 |
$48.20
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$141.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$26.88
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$161.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$9.60
|
| Rate for Payer: United Healthcare Commercial |
$161.00
|
| Rate for Payer: United Healthcare Medicare |
$25.60
|
| Rate for Payer: WellCare Child Health Plus/Family Health Plus/Medicaid |
$23.54
|
| Rate for Payer: WellCare Medicare |
$35.20
|
|
|
WHIRLPOOL THERAPY (W/ KX)
|
Facility
|
IP
|
$64.00
|
|
|
Service Code
|
HCPCS 97022 GP,KX
|
| Hospital Charge Code |
4650325
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$41.60 |
| Max. Negotiated Rate |
$41.60 |
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Galaxy Health Commercial |
$41.60
|
|
|
WHO W/NONTORSION JNT(S) CF
|
Facility
|
OP
|
$2,835.59
|
|
|
Service Code
|
HCPCS L3905
|
| Hospital Charge Code |
4690164
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$425.34 |
| Max. Negotiated Rate |
$2,268.47 |
| Rate for Payer: Aetna of NY Commercial |
$1,984.91
|
| Rate for Payer: Aetna of NY Medicare |
$1,304.37
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$1,134.24
|
| Rate for Payer: Cash Price |
$2,126.69
|
| Rate for Payer: CDPHP Medicare |
$1,049.17
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$1,417.80
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$2,268.47
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$2,268.47
|
| Rate for Payer: EmblemHealth Medicaid |
$2,268.47
|
| Rate for Payer: EmblemHealth Medicare |
$964.10
|
| Rate for Payer: EmblemHealth Select Care |
$1,417.80
|
| Rate for Payer: Fidelis Medicare |
$1,134.24
|
| Rate for Payer: Galaxy Health Commercial |
$1,843.13
|
| Rate for Payer: Hamaspik Choice Medicare |
$1,134.24
|
| Rate for Payer: Humana Medicare |
$1,134.24
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,984.91
|
| Rate for Payer: Local 1199SEIU Medicare |
$1,304.37
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,126.69
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$1,596.44
|
| Rate for Payer: MVP Health Care of NY Medicare |
$1,190.95
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$425.34
|
| Rate for Payer: United Healthcare Medicare |
$1,134.24
|
| Rate for Payer: WellCare Medicare |
$1,559.57
|
|
|
WHO W/NONTORSION JNT(S) CF
|
Facility
|
IP
|
$2,835.59
|
|
|
Service Code
|
HCPCS L3905
|
| Hospital Charge Code |
4690164
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$1,276.02 |
| Max. Negotiated Rate |
$1,843.13 |
| Rate for Payer: Cash Price |
$2,126.69
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$1,417.80
|
| Rate for Payer: EmblemHealth Select Care |
$1,417.80
|
| Rate for Payer: Galaxy Health Commercial |
$1,843.13
|
| Rate for Payer: Multiplan Commercial |
$1,276.02
|
| Rate for Payer: WellCare Medicare |
$1,559.57
|
|
|
WINDOWING OF CAST
|
Facility
|
IP
|
$498.00
|
|
|
Service Code
|
HCPCS 29730
|
| Hospital Charge Code |
4850165
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$323.70 |
| Max. Negotiated Rate |
$323.70 |
| Rate for Payer: Cash Price |
$373.50
|
| Rate for Payer: Galaxy Health Commercial |
$323.70
|
|
|
WINDOWING OF CAST
|
Facility
|
OP
|
$498.00
|
|
|
Service Code
|
HCPCS 29730
|
| Hospital Charge Code |
4850165
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$74.70 |
| Max. Negotiated Rate |
$398.40 |
| Rate for Payer: Aetna of NY Commercial |
$348.60
|
| Rate for Payer: Aetna of NY Medicare |
$229.08
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$199.20
|
| Rate for Payer: Cash Price |
$373.50
|
| Rate for Payer: CDPHP Medicare |
$184.26
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$398.40
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$398.40
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$398.40
|
| Rate for Payer: EmblemHealth Medicaid |
$398.40
|
| Rate for Payer: EmblemHealth Medicare |
$169.32
|
| Rate for Payer: EmblemHealth Select Care |
$358.56
|
| Rate for Payer: Fidelis Medicare |
$199.20
|
| Rate for Payer: Galaxy Health Commercial |
$323.70
|
| Rate for Payer: Hamaspik Choice Medicare |
$199.20
|
| Rate for Payer: Humana Medicare |
$199.20
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$348.60
|
| Rate for Payer: Local 1199SEIU Medicare |
$229.08
|
| Rate for Payer: MVP Health Care of NY Commercial |
$373.50
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$280.37
|
| Rate for Payer: MVP Health Care of NY Medicare |
$209.16
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$74.70
|
| Rate for Payer: United Healthcare Medicare |
$199.20
|
| Rate for Payer: WellCare Medicare |
$273.90
|
|
|
WIXELA 100-50 INHUB 100 mcg, 60 eaches
|
Facility
|
OP
|
$1,080.00
|
|
|
Service Code
|
HCPCS J3535
|
| Hospital Charge Code |
4401532
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$162.00 |
| Max. Negotiated Rate |
$864.00 |
| Rate for Payer: Aetna of NY Medicare |
$496.80
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$432.00
|
| Rate for Payer: Cash Price |
$810.00
|
| Rate for Payer: CDPHP Medicare |
$399.60
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$864.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$864.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$864.00
|
| Rate for Payer: EmblemHealth Medicaid |
$864.00
|
| Rate for Payer: EmblemHealth Medicare |
$367.20
|
| Rate for Payer: EmblemHealth Select Care |
$777.60
|
| Rate for Payer: Fidelis Medicare |
$432.00
|
| Rate for Payer: Galaxy Health Commercial |
$702.00
|
| Rate for Payer: Hamaspik Choice Medicare |
$432.00
|
| Rate for Payer: Humana Medicare |
$432.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$496.80
|
| Rate for Payer: MVP Health Care of NY Commercial |
$810.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$608.04
|
| Rate for Payer: MVP Health Care of NY Medicare |
$453.60
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$162.00
|
| Rate for Payer: United Healthcare Medicare |
$432.00
|
| Rate for Payer: WellCare Medicare |
$594.00
|
|
|
WIXELA 100-50 INHUB 100 mcg, 60 eaches
|
Facility
|
IP
|
$1,080.00
|
|
|
Service Code
|
HCPCS J3535
|
| Hospital Charge Code |
4401532
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$594.00 |
| Max. Negotiated Rate |
$702.00 |
| Rate for Payer: Aetna of NY Commercial |
$594.00
|
| Rate for Payer: Cash Price |
$810.00
|
| Rate for Payer: Galaxy Health Commercial |
$702.00
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$594.00
|
| Rate for Payer: WellCare Medicare |
$594.00
|
|
|
WIXELA 250-50 INHUB 250 mcg, 60 eaches
|
Facility
|
IP
|
$23.00
|
|
|
Service Code
|
NDC 378932132
|
| Hospital Charge Code |
4401539
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.65 |
| Max. Negotiated Rate |
$14.95 |
| Rate for Payer: Cash Price |
$17.25
|
| Rate for Payer: Galaxy Health Commercial |
$14.95
|
| Rate for Payer: WellCare Medicare |
$12.65
|
|
|
WIXELA 250-50 INHUB 250 mcg, 60 eaches
|
Facility
|
OP
|
$23.00
|
|
|
Service Code
|
NDC 378932132
|
| Hospital Charge Code |
4401539
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.45 |
| Max. Negotiated Rate |
$18.40 |
| Rate for Payer: Aetna of NY Commercial |
$16.10
|
| Rate for Payer: Aetna of NY Medicare |
$10.58
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$9.20
|
| Rate for Payer: Cash Price |
$17.25
|
| Rate for Payer: CDPHP Medicare |
$8.51
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$18.40
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$18.40
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$18.40
|
| Rate for Payer: EmblemHealth Medicaid |
$18.40
|
| Rate for Payer: EmblemHealth Medicare |
$7.82
|
| Rate for Payer: EmblemHealth Select Care |
$16.56
|
| Rate for Payer: Fidelis Medicare |
$9.20
|
| Rate for Payer: Galaxy Health Commercial |
$14.95
|
| Rate for Payer: Hamaspik Choice Medicare |
$9.20
|
| Rate for Payer: Humana Medicare |
$9.20
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$16.10
|
| Rate for Payer: Local 1199SEIU Medicare |
$10.58
|
| Rate for Payer: MVP Health Care of NY Commercial |
$17.25
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$12.95
|
| Rate for Payer: MVP Health Care of NY Medicare |
$9.66
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$3.45
|
| Rate for Payer: United Healthcare Medicare |
$9.20
|
| Rate for Payer: WellCare Medicare |
$12.65
|
|
|
WIXELA 500-50 INHUB 500 mcg, 60 eaches
|
Facility
|
OP
|
$1,775.00
|
|
|
Service Code
|
NDC 378932232
|
| Hospital Charge Code |
4401944
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$266.25 |
| Max. Negotiated Rate |
$1,420.00 |
| Rate for Payer: Aetna of NY Commercial |
$1,242.50
|
| Rate for Payer: Aetna of NY Medicare |
$816.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$710.00
|
| Rate for Payer: Cash Price |
$1,331.25
|
| Rate for Payer: CDPHP Medicare |
$656.75
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$1,420.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$1,420.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$1,420.00
|
| Rate for Payer: EmblemHealth Medicaid |
$1,420.00
|
| Rate for Payer: EmblemHealth Medicare |
$603.50
|
| Rate for Payer: EmblemHealth Select Care |
$1,278.00
|
| Rate for Payer: Fidelis Medicare |
$710.00
|
| Rate for Payer: Galaxy Health Commercial |
$1,153.75
|
| Rate for Payer: Hamaspik Choice Medicare |
$710.00
|
| Rate for Payer: Humana Medicare |
$710.00
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,242.50
|
| Rate for Payer: Local 1199SEIU Medicare |
$816.50
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,331.25
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$999.33
|
| Rate for Payer: MVP Health Care of NY Medicare |
$745.50
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$266.25
|
| Rate for Payer: United Healthcare Medicare |
$710.00
|
| Rate for Payer: WellCare Medicare |
$976.25
|
|
|
WIXELA 500-50 INHUB 500 mcg, 60 eaches
|
Facility
|
IP
|
$1,775.00
|
|
|
Service Code
|
NDC 378932232
|
| Hospital Charge Code |
4401944
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$976.25 |
| Max. Negotiated Rate |
$1,153.75 |
| Rate for Payer: Cash Price |
$1,331.25
|
| Rate for Payer: Galaxy Health Commercial |
$1,153.75
|
| Rate for Payer: WellCare Medicare |
$976.25
|
|
|
WORK HARDENING EA ADDTL 1.00 HR
|
Facility
|
OP
|
$73.13
|
|
|
Service Code
|
HCPCS 97546 GP
|
| Hospital Charge Code |
4650067
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$10.97 |
| Max. Negotiated Rate |
$238.54 |
| Rate for Payer: Aetna of NY Commercial |
$115.00
|
| Rate for Payer: Aetna of NY Medicare |
$33.64
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$29.25
|
| Rate for Payer: Cash Price |
$54.85
|
| Rate for Payer: Cash Price |
$54.85
|
| Rate for Payer: Cash Price |
$54.85
|
| Rate for Payer: CDPHP Medicare |
$27.06
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$58.50
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$133.14
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$110.95
|
| Rate for Payer: EmblemHealth Medicaid |
$110.95
|
| Rate for Payer: EmblemHealth Medicare |
$24.86
|
| Rate for Payer: EmblemHealth Select Care |
$52.65
|
| Rate for Payer: Fidelis Medicare |
$29.25
|
| Rate for Payer: Galaxy Health Commercial |
$47.53
|
| Rate for Payer: Galaxy Health Workers Comp |
$108.73
|
| Rate for Payer: Hamaspik Choice Medicaid |
$110.95
|
| Rate for Payer: Hamaspik Choice Medicare |
$29.25
|
| Rate for Payer: Humana Medicare |
$29.25
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$115.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$33.64
|
| Rate for Payer: MVP Health Care of NY Child Health Plus/Family Health Plus/HARP/Medicaid |
$116.50
|
| Rate for Payer: MVP Health Care of NY Commercial |
$187.00
|
| Rate for Payer: MVP Health Care of NY Essential Plan 1&2 |
$238.54
|
| Rate for Payer: MVP Health Care of NY Essential Plan 3&4 |
$238.54
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$141.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$30.71
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$161.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$10.97
|
| Rate for Payer: United Healthcare Commercial |
$161.00
|
| Rate for Payer: United Healthcare Medicare |
$29.25
|
| Rate for Payer: WellCare Child Health Plus/Family Health Plus/Medicaid |
$116.50
|
| Rate for Payer: WellCare Medicare |
$40.22
|
|
|
WORK HARDENING EA ADDTL 1.00 HR
|
Facility
|
IP
|
$73.13
|
|
|
Service Code
|
HCPCS 97546 GP
|
| Hospital Charge Code |
4650067
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$47.53 |
| Max. Negotiated Rate |
$47.53 |
| Rate for Payer: Cash Price |
$54.85
|
| Rate for Payer: Galaxy Health Commercial |
$47.53
|
|
|
WORK HARDENING EA ADDTL 1.00 HR (MOD 59)
|
Facility
|
OP
|
$73.13
|
|
|
Service Code
|
HCPCS 97546 GP,59
|
| Hospital Charge Code |
4650388
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$10.97 |
| Max. Negotiated Rate |
$238.54 |
| Rate for Payer: Aetna of NY Commercial |
$115.00
|
| Rate for Payer: Aetna of NY Medicare |
$33.64
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$29.25
|
| Rate for Payer: Cash Price |
$54.85
|
| Rate for Payer: Cash Price |
$54.85
|
| Rate for Payer: Cash Price |
$54.85
|
| Rate for Payer: CDPHP Medicare |
$27.06
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$58.50
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$133.14
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$110.95
|
| Rate for Payer: EmblemHealth Medicaid |
$110.95
|
| Rate for Payer: EmblemHealth Medicare |
$24.86
|
| Rate for Payer: EmblemHealth Select Care |
$52.65
|
| Rate for Payer: Fidelis Medicare |
$29.25
|
| Rate for Payer: Galaxy Health Commercial |
$47.53
|
| Rate for Payer: Galaxy Health Workers Comp |
$108.73
|
| Rate for Payer: Hamaspik Choice Medicaid |
$110.95
|
| Rate for Payer: Hamaspik Choice Medicare |
$29.25
|
| Rate for Payer: Humana Medicare |
$29.25
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$115.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$33.64
|
| Rate for Payer: MVP Health Care of NY Child Health Plus/Family Health Plus/HARP/Medicaid |
$116.50
|
| Rate for Payer: MVP Health Care of NY Commercial |
$187.00
|
| Rate for Payer: MVP Health Care of NY Essential Plan 1&2 |
$238.54
|
| Rate for Payer: MVP Health Care of NY Essential Plan 3&4 |
$238.54
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$141.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$30.71
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$161.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$10.97
|
| Rate for Payer: United Healthcare Commercial |
$161.00
|
| Rate for Payer: United Healthcare Medicare |
$29.25
|
| Rate for Payer: WellCare Child Health Plus/Family Health Plus/Medicaid |
$116.50
|
| Rate for Payer: WellCare Medicare |
$40.22
|
|
|
WORK HARDENING EA ADDTL 1.00 HR (MOD 59)
|
Facility
|
IP
|
$73.13
|
|
|
Service Code
|
HCPCS 97546 GP,59
|
| Hospital Charge Code |
4650388
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$47.53 |
| Max. Negotiated Rate |
$47.53 |
| Rate for Payer: Cash Price |
$54.85
|
| Rate for Payer: Galaxy Health Commercial |
$47.53
|
|
|
WORK HARDENING EA ADDTL 1.00 HR (MOD 59 W KX)
|
Facility
|
IP
|
$73.13
|
|
|
Service Code
|
HCPCS 97546 GP,59,KX
|
| Hospital Charge Code |
4650440
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$47.53 |
| Max. Negotiated Rate |
$47.53 |
| Rate for Payer: Cash Price |
$54.85
|
| Rate for Payer: Galaxy Health Commercial |
$47.53
|
|
|
WORK HARDENING EA ADDTL 1.00 HR (MOD 59 W KX)
|
Facility
|
OP
|
$73.13
|
|
|
Service Code
|
HCPCS 97546 GP,59,KX
|
| Hospital Charge Code |
4650440
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$10.97 |
| Max. Negotiated Rate |
$238.54 |
| Rate for Payer: Aetna of NY Commercial |
$115.00
|
| Rate for Payer: Aetna of NY Medicare |
$33.64
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$29.25
|
| Rate for Payer: Cash Price |
$54.85
|
| Rate for Payer: Cash Price |
$54.85
|
| Rate for Payer: Cash Price |
$54.85
|
| Rate for Payer: CDPHP Medicare |
$27.06
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$58.50
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$133.14
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$110.95
|
| Rate for Payer: EmblemHealth Medicaid |
$110.95
|
| Rate for Payer: EmblemHealth Medicare |
$24.86
|
| Rate for Payer: EmblemHealth Select Care |
$52.65
|
| Rate for Payer: Fidelis Medicare |
$29.25
|
| Rate for Payer: Galaxy Health Commercial |
$47.53
|
| Rate for Payer: Galaxy Health Workers Comp |
$108.73
|
| Rate for Payer: Hamaspik Choice Medicaid |
$110.95
|
| Rate for Payer: Hamaspik Choice Medicare |
$29.25
|
| Rate for Payer: Humana Medicare |
$29.25
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$115.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$33.64
|
| Rate for Payer: MVP Health Care of NY Child Health Plus/Family Health Plus/HARP/Medicaid |
$116.50
|
| Rate for Payer: MVP Health Care of NY Commercial |
$187.00
|
| Rate for Payer: MVP Health Care of NY Essential Plan 1&2 |
$238.54
|
| Rate for Payer: MVP Health Care of NY Essential Plan 3&4 |
$238.54
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$141.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$30.71
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$161.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$10.97
|
| Rate for Payer: United Healthcare Commercial |
$161.00
|
| Rate for Payer: United Healthcare Medicare |
$29.25
|
| Rate for Payer: WellCare Child Health Plus/Family Health Plus/Medicaid |
$116.50
|
| Rate for Payer: WellCare Medicare |
$40.22
|
|
|
WORK HARDENING EA ADDTL 1.00 HR (W/ KX)
|
Facility
|
OP
|
$73.13
|
|
|
Service Code
|
HCPCS 97546 GP,KX
|
| Hospital Charge Code |
4650336
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$10.97 |
| Max. Negotiated Rate |
$238.54 |
| Rate for Payer: Aetna of NY Commercial |
$115.00
|
| Rate for Payer: Aetna of NY Medicare |
$33.64
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$29.25
|
| Rate for Payer: Cash Price |
$54.85
|
| Rate for Payer: Cash Price |
$54.85
|
| Rate for Payer: Cash Price |
$54.85
|
| Rate for Payer: CDPHP Medicare |
$27.06
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$58.50
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$133.14
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$110.95
|
| Rate for Payer: EmblemHealth Medicaid |
$110.95
|
| Rate for Payer: EmblemHealth Medicare |
$24.86
|
| Rate for Payer: EmblemHealth Select Care |
$52.65
|
| Rate for Payer: Fidelis Medicare |
$29.25
|
| Rate for Payer: Galaxy Health Commercial |
$47.53
|
| Rate for Payer: Galaxy Health Workers Comp |
$108.73
|
| Rate for Payer: Hamaspik Choice Medicaid |
$110.95
|
| Rate for Payer: Hamaspik Choice Medicare |
$29.25
|
| Rate for Payer: Humana Medicare |
$29.25
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$115.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$33.64
|
| Rate for Payer: MVP Health Care of NY Child Health Plus/Family Health Plus/HARP/Medicaid |
$116.50
|
| Rate for Payer: MVP Health Care of NY Commercial |
$187.00
|
| Rate for Payer: MVP Health Care of NY Essential Plan 1&2 |
$238.54
|
| Rate for Payer: MVP Health Care of NY Essential Plan 3&4 |
$238.54
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$141.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$30.71
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$161.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$10.97
|
| Rate for Payer: United Healthcare Commercial |
$161.00
|
| Rate for Payer: United Healthcare Medicare |
$29.25
|
| Rate for Payer: WellCare Child Health Plus/Family Health Plus/Medicaid |
$116.50
|
| Rate for Payer: WellCare Medicare |
$40.22
|
|
