|
DELIVERY OF PLACENTA
|
Facility
|
IP
|
$8,946.00
|
|
|
Service Code
|
HCPCS 59414
|
| Hospital Charge Code |
4602215
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$5,814.90 |
| Max. Negotiated Rate |
$5,814.90 |
| Rate for Payer: Cash Price |
$6,709.50
|
| Rate for Payer: Galaxy Health Commercial |
$5,814.90
|
|
|
DELIVERY OF PLACENTA
|
Facility
|
OP
|
$8,946.00
|
|
|
Service Code
|
HCPCS 59414
|
| Hospital Charge Code |
4602215
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$250.00 |
| Max. Negotiated Rate |
$7,201.53 |
| Rate for Payer: Aetna of NY Commercial |
$955.00
|
| Rate for Payer: Aetna of NY Medicare |
$4,115.16
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$950.93
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$1,189.18
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$3,310.02
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$4,473.00
|
| Rate for Payer: Cash Price |
$6,709.50
|
| Rate for Payer: Cash Price |
$6,709.50
|
| Rate for Payer: Cash Price |
$6,709.50
|
| Rate for Payer: Cash Price |
$6,709.50
|
| Rate for Payer: CDPHP Commercial |
$7,201.53
|
| Rate for Payer: CDPHP Medicare |
$3,310.02
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$1,182.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$7,156.80
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$7,156.80
|
| Rate for Payer: EmblemHealth Medicaid |
$7,156.80
|
| Rate for Payer: EmblemHealth Medicare |
$3,041.64
|
| Rate for Payer: EmblemHealth Select Care |
$1,064.00
|
| Rate for Payer: Fidelis Child Health Plus/Essential Plan/HARP/Medicaid |
$250.00
|
| Rate for Payer: Fidelis Medicare |
$3,409.32
|
| Rate for Payer: Galaxy Health Commercial |
$5,814.90
|
| Rate for Payer: Hamaspik Choice Medicare |
$3,310.02
|
| Rate for Payer: Humana Medicare |
$3,310.02
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$955.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$4,115.16
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,174.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$881.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$3,475.52
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$980.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$2,978.77
|
| Rate for Payer: United Healthcare Commercial |
$980.00
|
| Rate for Payer: United Healthcare Medicare |
$3,310.02
|
| Rate for Payer: WellCare Medicare |
$4,920.30
|
|
|
DELZICOL 400 MG CAPSULE
|
Facility
|
OP
|
$11.07
|
|
|
Service Code
|
NDC 00023585318
|
| Hospital Charge Code |
4409133
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.76 |
| Max. Negotiated Rate |
$8.91 |
| Rate for Payer: Aetna of NY Commercial |
$7.75
|
| Rate for Payer: Aetna of NY Medicare |
$5.09
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$8.30
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$8.30
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$4.10
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$5.54
|
| Rate for Payer: Cash Price |
$8.30
|
| Rate for Payer: CDPHP Commercial |
$8.91
|
| Rate for Payer: CDPHP Medicare |
$4.10
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$8.86
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$8.86
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$8.86
|
| Rate for Payer: EmblemHealth Medicaid |
$8.86
|
| Rate for Payer: EmblemHealth Medicare |
$3.76
|
| Rate for Payer: EmblemHealth Select Care |
$7.97
|
| Rate for Payer: Fidelis Medicare |
$4.22
|
| Rate for Payer: Galaxy Health Commercial |
$7.20
|
| Rate for Payer: Hamaspik Choice Medicare |
$4.10
|
| Rate for Payer: Humana Medicare |
$4.10
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$7.75
|
| Rate for Payer: Local 1199SEIU Medicare |
$5.09
|
| Rate for Payer: MVP Health Care of NY Commercial |
$8.30
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$6.23
|
| Rate for Payer: MVP Health Care of NY Medicare |
$4.30
|
| Rate for Payer: United Healthcare Medicare |
$4.10
|
| Rate for Payer: WellCare Medicare |
$6.09
|
|
|
DELZICOL 400 MG CAPSULE
|
Facility
|
IP
|
$11.07
|
|
|
Service Code
|
NDC 00023585318
|
| Hospital Charge Code |
4409133
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.09 |
| Max. Negotiated Rate |
$7.20 |
| Rate for Payer: Cash Price |
$8.30
|
| Rate for Payer: Galaxy Health Commercial |
$7.20
|
| Rate for Payer: WellCare Medicare |
$6.09
|
|
|
DEPAKOTE LEVEL/VALPORIC ACID (VALPORATE)
|
Facility
|
OP
|
$52.00
|
|
|
Service Code
|
HCPCS 80164
|
| Hospital Charge Code |
4300820
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$10.61 |
| Max. Negotiated Rate |
$41.86 |
| Rate for Payer: Aetna of NY Commercial |
$33.80
|
| Rate for Payer: Aetna of NY Medicare |
$23.92
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$39.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$39.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$19.24
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$26.00
|
| Rate for Payer: Cash Price |
$39.00
|
| Rate for Payer: Cash Price |
$39.00
|
| Rate for Payer: CDPHP Commercial |
$41.86
|
| Rate for Payer: CDPHP Medicare |
$19.24
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$31.20
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$41.60
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$41.60
|
| Rate for Payer: EmblemHealth Medicaid |
$41.60
|
| Rate for Payer: EmblemHealth Medicare |
$17.68
|
| Rate for Payer: EmblemHealth Select Care |
$31.20
|
| Rate for Payer: Fidelis Medicare |
$19.82
|
| Rate for Payer: Galaxy Health Commercial |
$33.80
|
| Rate for Payer: Hamaspik Choice Medicare |
$19.24
|
| Rate for Payer: Humana Medicare |
$19.24
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$33.80
|
| Rate for Payer: Local 1199SEIU Medicare |
$23.92
|
| Rate for Payer: MVP Health Care of NY Commercial |
$39.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$29.28
|
| Rate for Payer: MVP Health Care of NY Medicare |
$20.20
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$39.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$10.61
|
| Rate for Payer: United Healthcare Commercial |
$39.00
|
| Rate for Payer: United Healthcare Medicare |
$19.24
|
| Rate for Payer: WellCare Medicare |
$28.60
|
|
|
DEPAKOTE LEVEL/VALPORIC ACID (VALPORATE)
|
Facility
|
IP
|
$52.00
|
|
|
Service Code
|
HCPCS 80164
|
| Hospital Charge Code |
4300820
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$33.80 |
| Max. Negotiated Rate |
$33.80 |
| Rate for Payer: Cash Price |
$39.00
|
| Rate for Payer: Galaxy Health Commercial |
$33.80
|
|
|
DESTRUCT B9 LESION 1-14
|
Facility
|
IP
|
$573.00
|
|
|
Service Code
|
HCPCS 17110
|
| Hospital Charge Code |
4856727
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$372.45 |
| Max. Negotiated Rate |
$372.45 |
| Rate for Payer: Cash Price |
$429.75
|
| Rate for Payer: Galaxy Health Commercial |
$372.45
|
|
|
DESTRUCT B9 LESION 1-14
|
Facility
|
OP
|
$573.00
|
|
|
Service Code
|
HCPCS 17110
|
| Hospital Charge Code |
4856727
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$190.75 |
| Max. Negotiated Rate |
$2,521.93 |
| Rate for Payer: Aetna of NY Commercial |
$401.10
|
| Rate for Payer: Aetna of NY Medicare |
$263.58
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$2,017.33
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$2,521.93
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$212.01
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$286.50
|
| Rate for Payer: Cash Price |
$429.75
|
| Rate for Payer: Cash Price |
$429.75
|
| Rate for Payer: Cash Price |
$429.75
|
| Rate for Payer: CDPHP Commercial |
$461.26
|
| Rate for Payer: CDPHP Medicare |
$212.01
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$458.40
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$458.40
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$458.40
|
| Rate for Payer: EmblemHealth Medicaid |
$458.40
|
| Rate for Payer: EmblemHealth Medicare |
$194.82
|
| Rate for Payer: EmblemHealth Select Care |
$412.56
|
| Rate for Payer: Fidelis Medicare |
$218.37
|
| Rate for Payer: Galaxy Health Commercial |
$372.45
|
| Rate for Payer: Hamaspik Choice Medicare |
$212.01
|
| Rate for Payer: Humana Medicare |
$212.01
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$401.10
|
| Rate for Payer: Local 1199SEIU Medicare |
$263.58
|
| Rate for Payer: MVP Health Care of NY Commercial |
$429.75
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$322.60
|
| Rate for Payer: MVP Health Care of NY Medicare |
$222.61
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$190.75
|
| Rate for Payer: United Healthcare Medicare |
$212.01
|
| Rate for Payer: WellCare Medicare |
$315.15
|
|
|
DESTRUCTION BY NEUROLYTIC AGENT, GENICULAR NERVE BRANCHES INCLUDING IMAGING GUIDANCE, WHEN PERFORMED
|
Facility
|
OP
|
$2,521.93
|
|
|
Service Code
|
CPT 64624
|
|
Hospital Revenue Code
|
490
|
| Min. Negotiated Rate |
$1,266.00 |
| Max. Negotiated Rate |
$2,521.93 |
| Rate for Payer: Aetna of NY Commercial |
$1,857.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$2,017.33
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$2,521.93
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$1,266.00
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,857.00
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$1,775.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$1,839.63
|
| Rate for Payer: United Healthcare Commercial |
$2,036.00
|
|
|
DESTRUCTION BY NEUROLYTIC AGENT; OTHER PERIPHERAL NERVE OR BRANCH
|
Facility
|
OP
|
$2,521.93
|
|
|
Service Code
|
CPT 64640
|
|
Hospital Revenue Code
|
490
|
| Min. Negotiated Rate |
$636.00 |
| Max. Negotiated Rate |
$2,521.93 |
| Rate for Payer: Aetna of NY Commercial |
$1,857.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$2,017.33
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$2,521.93
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$636.00
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,857.00
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$1,775.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$868.45
|
| Rate for Payer: United Healthcare Commercial |
$1,775.00
|
|
|
DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
|
Facility
|
OP
|
$2,521.93
|
|
|
Service Code
|
CPT 64634
|
|
Hospital Revenue Code
|
490
|
| Min. Negotiated Rate |
$66.24 |
| Max. Negotiated Rate |
$2,521.93 |
| Rate for Payer: Aetna of NY Commercial |
$1,857.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$2,017.33
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$2,521.93
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$636.00
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,857.00
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$1,775.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$66.24
|
| Rate for Payer: United Healthcare Commercial |
$1,775.00
|
|
|
DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, SINGLE FACET JOINT
|
Facility
|
OP
|
$2,521.93
|
|
|
Service Code
|
CPT 64633
|
|
Hospital Revenue Code
|
490
|
| Min. Negotiated Rate |
$1,266.00 |
| Max. Negotiated Rate |
$2,521.93 |
| Rate for Payer: Aetna of NY Commercial |
$1,857.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$2,017.33
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$2,521.93
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$1,266.00
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,857.00
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$1,775.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$1,839.63
|
| Rate for Payer: United Healthcare Commercial |
$2,036.00
|
|
|
DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
|
Facility
|
OP
|
$2,521.93
|
|
|
Service Code
|
CPT 64636
|
|
Hospital Revenue Code
|
490
|
| Min. Negotiated Rate |
$57.92 |
| Max. Negotiated Rate |
$2,521.93 |
| Rate for Payer: Aetna of NY Commercial |
$1,857.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$2,017.33
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$2,521.93
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$636.00
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,857.00
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$1,775.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$57.92
|
| Rate for Payer: United Healthcare Commercial |
$1,775.00
|
|
|
DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT
|
Facility
|
OP
|
$2,521.93
|
|
|
Service Code
|
CPT 64635
|
|
Hospital Revenue Code
|
490
|
| Min. Negotiated Rate |
$1,266.00 |
| Max. Negotiated Rate |
$2,521.93 |
| Rate for Payer: Aetna of NY Commercial |
$1,857.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$2,017.33
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$2,521.93
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$1,266.00
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,857.00
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$1,775.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$1,839.63
|
| Rate for Payer: United Healthcare Commercial |
$2,036.00
|
|
|
DETROL LA 2 MG
|
Facility
|
IP
|
$38.11
|
|
|
Service Code
|
NDC 51079019701
|
| Hospital Charge Code |
4409010
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$20.96 |
| Max. Negotiated Rate |
$24.77 |
| Rate for Payer: Cash Price |
$28.58
|
| Rate for Payer: Galaxy Health Commercial |
$24.77
|
| Rate for Payer: WellCare Medicare |
$20.96
|
|
|
DETROL LA 2 MG
|
Facility
|
OP
|
$38.11
|
|
|
Service Code
|
NDC 51079019701
|
| Hospital Charge Code |
4409010
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.96 |
| Max. Negotiated Rate |
$30.68 |
| Rate for Payer: Aetna of NY Commercial |
$26.68
|
| Rate for Payer: Aetna of NY Medicare |
$17.53
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$28.58
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$28.58
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$14.10
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$19.06
|
| Rate for Payer: Cash Price |
$28.58
|
| Rate for Payer: CDPHP Commercial |
$30.68
|
| Rate for Payer: CDPHP Medicare |
$14.10
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$30.49
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$30.49
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$30.49
|
| Rate for Payer: EmblemHealth Medicaid |
$30.49
|
| Rate for Payer: EmblemHealth Medicare |
$12.96
|
| Rate for Payer: EmblemHealth Select Care |
$27.44
|
| Rate for Payer: Fidelis Medicare |
$14.52
|
| Rate for Payer: Galaxy Health Commercial |
$24.77
|
| Rate for Payer: Hamaspik Choice Medicare |
$14.10
|
| Rate for Payer: Humana Medicare |
$14.10
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$26.68
|
| Rate for Payer: Local 1199SEIU Medicare |
$17.53
|
| Rate for Payer: MVP Health Care of NY Commercial |
$28.58
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$21.46
|
| Rate for Payer: MVP Health Care of NY Medicare |
$14.81
|
| Rate for Payer: United Healthcare Medicare |
$14.10
|
| Rate for Payer: WellCare Medicare |
$20.96
|
|
|
DEVICE 5MM ENDO PEANUT LAPAR
|
Facility
|
OP
|
$283.00
|
|
| Hospital Charge Code |
4471176
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$96.22 |
| Max. Negotiated Rate |
$227.82 |
| Rate for Payer: Aetna of NY Commercial |
$198.10
|
| Rate for Payer: Aetna of NY Medicare |
$130.18
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$212.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$212.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$104.71
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$141.50
|
| Rate for Payer: Cash Price |
$212.25
|
| Rate for Payer: CDPHP Commercial |
$227.82
|
| Rate for Payer: CDPHP Medicare |
$104.71
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$226.40
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$226.40
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$226.40
|
| Rate for Payer: EmblemHealth Medicaid |
$226.40
|
| Rate for Payer: EmblemHealth Medicare |
$96.22
|
| Rate for Payer: EmblemHealth Select Care |
$203.76
|
| Rate for Payer: Fidelis Medicare |
$107.85
|
| Rate for Payer: Galaxy Health Commercial |
$183.95
|
| Rate for Payer: Hamaspik Choice Medicare |
$104.71
|
| Rate for Payer: Humana Medicare |
$104.71
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$198.10
|
| Rate for Payer: Local 1199SEIU Medicare |
$130.18
|
| Rate for Payer: MVP Health Care of NY Commercial |
$212.25
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$159.33
|
| Rate for Payer: MVP Health Care of NY Medicare |
$109.95
|
| Rate for Payer: United Healthcare Medicare |
$104.71
|
| Rate for Payer: WellCare Medicare |
$155.65
|
|
|
DEVICE 5MM ENDO PEANUT LAPAR
|
Facility
|
IP
|
$283.00
|
|
| Hospital Charge Code |
4471176
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$183.95 |
| Max. Negotiated Rate |
$183.95 |
| Rate for Payer: Cash Price |
$212.25
|
| Rate for Payer: Galaxy Health Commercial |
$183.95
|
|
|
DEXAMETHASONE 0.75MG TABS 10X10EA
|
Facility
|
IP
|
$6.18
|
|
|
Service Code
|
NDC 00054818025
|
| Hospital Charge Code |
4400216
|
|
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
|
|
|
DEXAMETHASONE 0.75MG TABS 10X10EA
|
Facility
|
OP
|
$6.18
|
|
|
Service Code
|
NDC 00054818025
|
| Hospital Charge Code |
4400216
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.10 |
| Max. Negotiated Rate |
$4.97 |
| 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) Blue Access/Small Group |
$4.64
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$4.64
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$2.29
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$3.09
|
| Rate for Payer: Cash Price |
$4.64
|
| Rate for Payer: CDPHP Commercial |
$4.97
|
| 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 |
$2.36
|
| Rate for Payer: Galaxy Health Commercial |
$4.02
|
| Rate for Payer: Hamaspik Choice Medicare |
$2.29
|
| Rate for Payer: Humana Medicare |
$2.29
|
| 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 |
$4.64
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$3.48
|
| Rate for Payer: MVP Health Care of NY Medicare |
$2.40
|
| Rate for Payer: United Healthcare Medicare |
$2.29
|
| Rate for Payer: WellCare Medicare |
$3.40
|
|
|
dexAMETHasone 4 MG TABLET 4 mg, 100 eaches
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
HCPCS J8540
|
| Hospital Charge Code |
4401463
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$4.83 |
| Rate for Payer: Aetna of NY Commercial |
$3.30
|
| Rate for Payer: Aetna of NY Medicare |
$2.76
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$0.07
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$0.07
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$2.22
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$3.00
|
| Rate for Payer: Cash Price |
$4.50
|
| Rate for Payer: Cash Price |
$4.50
|
| Rate for Payer: CDPHP Commercial |
$4.83
|
| Rate for Payer: CDPHP Medicare |
$2.22
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$0.07
|
| 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 |
$0.07
|
| Rate for Payer: Fidelis Medicare |
$2.29
|
| Rate for Payer: Galaxy Health Commercial |
$3.90
|
| Rate for Payer: Hamaspik Choice Medicare |
$2.22
|
| Rate for Payer: Humana Medicare |
$2.22
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$3.30
|
| 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 |
$2.33
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$0.17
|
| Rate for Payer: United Healthcare Commercial |
$0.17
|
| Rate for Payer: United Healthcare Medicare |
$2.22
|
| Rate for Payer: WellCare Medicare |
$3.30
|
|
|
dexAMETHasone 4 MG TABLET 4 mg, 100 eaches
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
HCPCS J8540
|
| Hospital Charge Code |
4401463
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$3.90 |
| Rate for Payer: Aetna of NY Commercial |
$3.30
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$0.07
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$0.07
|
| Rate for Payer: Cash Price |
$4.50
|
| Rate for Payer: Cash Price |
$4.50
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$0.07
|
| Rate for Payer: EmblemHealth Select Care |
$0.07
|
| Rate for Payer: Galaxy Health Commercial |
$3.90
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$3.30
|
| Rate for Payer: WellCare Medicare |
$3.30
|
|
|
DEXAMETHASONE SODIUM PHOSPHATE, 1 MG
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
HCPCS J1100
|
| Hospital Charge Code |
4400217
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.81 |
| Rate for Payer: Aetna of NY Commercial |
$0.55
|
| Rate for Payer: Aetna of NY Medicare |
$0.46
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$0.12
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$0.12
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$0.37
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$0.50
|
| Rate for Payer: Cash Price |
$0.75
|
| Rate for Payer: Cash Price |
$0.75
|
| Rate for Payer: CDPHP Commercial |
$0.81
|
| Rate for Payer: CDPHP Medicare |
$0.37
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$0.12
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$0.80
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$0.80
|
| Rate for Payer: EmblemHealth Medicaid |
$0.80
|
| Rate for Payer: EmblemHealth Medicare |
$0.34
|
| Rate for Payer: EmblemHealth Select Care |
$0.12
|
| Rate for Payer: Fidelis Medicare |
$0.38
|
| Rate for Payer: Galaxy Health Commercial |
$0.65
|
| Rate for Payer: Hamaspik Choice Medicare |
$0.37
|
| Rate for Payer: Humana Medicare |
$0.37
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$0.55
|
| Rate for Payer: Local 1199SEIU Medicare |
$0.46
|
| Rate for Payer: MVP Health Care of NY Commercial |
$0.75
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$0.56
|
| Rate for Payer: MVP Health Care of NY Medicare |
$0.39
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$0.20
|
| Rate for Payer: United Healthcare Commercial |
$0.20
|
| Rate for Payer: United Healthcare Medicare |
$0.37
|
| Rate for Payer: WellCare Medicare |
$0.55
|
|
|
DEXAMETHASONE SODIUM PHOSPHATE, 1 MG
|
Facility
|
IP
|
$0.36
|
|
|
Service Code
|
HCPCS J1100
|
| Hospital Charge Code |
4400219
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Aetna of NY Commercial |
$0.20
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$0.12
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$0.12
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$0.12
|
| Rate for Payer: EmblemHealth Select Care |
$0.12
|
| Rate for Payer: Galaxy Health Commercial |
$0.23
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$0.20
|
| Rate for Payer: WellCare Medicare |
$0.20
|
|
|
DEXAMETHASONE SODIUM PHOSPHATE, 1 MG
|
Facility
|
OP
|
$0.36
|
|
|
Service Code
|
HCPCS J1100
|
| Hospital Charge Code |
4400219
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Aetna of NY Commercial |
$0.20
|
| Rate for Payer: Aetna of NY Medicare |
$0.17
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$0.12
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$0.12
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$0.13
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$0.18
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: CDPHP Commercial |
$0.29
|
| Rate for Payer: CDPHP Medicare |
$0.13
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$0.12
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$0.29
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$0.29
|
| Rate for Payer: EmblemHealth Medicaid |
$0.29
|
| Rate for Payer: EmblemHealth Medicare |
$0.12
|
| Rate for Payer: EmblemHealth Select Care |
$0.12
|
| Rate for Payer: Fidelis Medicare |
$0.14
|
| Rate for Payer: Galaxy Health Commercial |
$0.23
|
| Rate for Payer: Hamaspik Choice Medicare |
$0.13
|
| Rate for Payer: Humana Medicare |
$0.13
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$0.20
|
| Rate for Payer: Local 1199SEIU Medicare |
$0.17
|
| Rate for Payer: MVP Health Care of NY Commercial |
$0.27
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$0.20
|
| Rate for Payer: MVP Health Care of NY Medicare |
$0.14
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$0.20
|
| Rate for Payer: United Healthcare Commercial |
$0.20
|
| Rate for Payer: United Healthcare Medicare |
$0.13
|
| Rate for Payer: WellCare Medicare |
$0.20
|
|
