|
DIGITAL BREAST TOMOSYNTHESIS, BILATERAL (NON-MEDICARE)
|
Facility
|
OP
|
$89.00
|
|
|
Service Code
|
HCPCS 77062 26
|
| Hospital Charge Code |
5150406
|
|
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
|
|
|
DIGITAL BREAST TOMOSYNTHESIS, BILATERAL (NON-MEDICARE)
|
Facility
|
IP
|
$89.00
|
|
|
Service Code
|
HCPCS 77062 26
|
| Hospital Charge Code |
5150406
|
|
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
|
|
|
DIGITAL BREAST TOMOSYNTHESIS UNILATERAL, LEFT (NON-MEDICARE)
|
Facility
|
IP
|
$89.00
|
|
|
Service Code
|
HCPCS 77061 26,LT
|
| Hospital Charge Code |
5150412
|
|
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
|
|
|
DIGITAL BREAST TOMOSYNTHESIS UNILATERAL, LEFT (NON-MEDICARE)
|
Facility
|
OP
|
$89.00
|
|
|
Service Code
|
HCPCS 77061 26,LT
|
| Hospital Charge Code |
5150412
|
|
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
|
|
|
DIGITAL BREAST TOMOSYNTHESIS UNILATERAL, LEFT (NON-MEDICARE)
|
Facility
|
IP
|
$194.67
|
|
|
Service Code
|
HCPCS 77061 LT,TC
|
| Hospital Charge Code |
4150412
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$126.54 |
| Max. Negotiated Rate |
$126.54 |
| Rate for Payer: Cash Price |
$146.00
|
| Rate for Payer: Galaxy Health Commercial |
$126.54
|
|
|
DIGITAL BREAST TOMOSYNTHESIS UNILATERAL, LEFT (NON-MEDICARE)
|
Facility
|
OP
|
$194.67
|
|
|
Service Code
|
HCPCS 77061 LT,TC
|
| Hospital Charge Code |
4150412
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$29.20 |
| Max. Negotiated Rate |
$489.00 |
| Rate for Payer: Aetna of NY Commercial |
$136.27
|
| Rate for Payer: Aetna of NY Medicare |
$89.55
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$77.87
|
| Rate for Payer: Cash Price |
$146.00
|
| Rate for Payer: Cash Price |
$146.00
|
| Rate for Payer: CDPHP Medicare |
$72.03
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$136.27
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$155.74
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$155.74
|
| Rate for Payer: EmblemHealth Medicaid |
$155.74
|
| Rate for Payer: EmblemHealth Medicare |
$66.19
|
| Rate for Payer: EmblemHealth Select Care |
$126.54
|
| Rate for Payer: Fidelis Medicare |
$77.87
|
| Rate for Payer: Galaxy Health Commercial |
$126.54
|
| Rate for Payer: Hamaspik Choice Medicare |
$77.87
|
| Rate for Payer: Humana Medicare |
$77.87
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$136.27
|
| Rate for Payer: Local 1199SEIU Medicare |
$89.55
|
| Rate for Payer: MVP Health Care of NY Commercial |
$146.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$109.60
|
| Rate for Payer: MVP Health Care of NY Medicare |
$81.76
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$489.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$29.20
|
| Rate for Payer: United Healthcare Commercial |
$489.00
|
| Rate for Payer: United Healthcare Medicare |
$77.87
|
| Rate for Payer: WellCare Medicare |
$107.07
|
|
|
DIGITAL BREAST TOMOSYNTHESIS UNILATERAL (NON-MEDICARE)
|
Facility
|
IP
|
$194.67
|
|
|
Service Code
|
HCPCS 77061 TC
|
| Hospital Charge Code |
4150405
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$126.54 |
| Max. Negotiated Rate |
$126.54 |
| Rate for Payer: Cash Price |
$146.00
|
| Rate for Payer: Galaxy Health Commercial |
$126.54
|
|
|
DIGITAL BREAST TOMOSYNTHESIS UNILATERAL (NON-MEDICARE)
|
Facility
|
OP
|
$194.67
|
|
|
Service Code
|
HCPCS 77061 TC
|
| Hospital Charge Code |
4150405
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$29.20 |
| Max. Negotiated Rate |
$489.00 |
| Rate for Payer: Aetna of NY Commercial |
$136.27
|
| Rate for Payer: Aetna of NY Medicare |
$89.55
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$77.87
|
| Rate for Payer: Cash Price |
$146.00
|
| Rate for Payer: Cash Price |
$146.00
|
| Rate for Payer: CDPHP Medicare |
$72.03
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$136.27
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$155.74
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$155.74
|
| Rate for Payer: EmblemHealth Medicaid |
$155.74
|
| Rate for Payer: EmblemHealth Medicare |
$66.19
|
| Rate for Payer: EmblemHealth Select Care |
$126.54
|
| Rate for Payer: Fidelis Medicare |
$77.87
|
| Rate for Payer: Galaxy Health Commercial |
$126.54
|
| Rate for Payer: Hamaspik Choice Medicare |
$77.87
|
| Rate for Payer: Humana Medicare |
$77.87
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$136.27
|
| Rate for Payer: Local 1199SEIU Medicare |
$89.55
|
| Rate for Payer: MVP Health Care of NY Commercial |
$146.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$109.60
|
| Rate for Payer: MVP Health Care of NY Medicare |
$81.76
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$489.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$29.20
|
| Rate for Payer: United Healthcare Commercial |
$489.00
|
| Rate for Payer: United Healthcare Medicare |
$77.87
|
| Rate for Payer: WellCare Medicare |
$107.07
|
|
|
DIGITAL BREAST TOMOSYNTHESIS UNILATERAL, RIGHT (NON-MEDICARE)
|
Facility
|
IP
|
$194.67
|
|
|
Service Code
|
HCPCS 77061 RT,TC
|
| Hospital Charge Code |
4150413
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$126.54 |
| Max. Negotiated Rate |
$126.54 |
| Rate for Payer: Cash Price |
$146.00
|
| Rate for Payer: Galaxy Health Commercial |
$126.54
|
|
|
DIGITAL BREAST TOMOSYNTHESIS UNILATERAL, RIGHT (NON-MEDICARE)
|
Facility
|
IP
|
$89.00
|
|
|
Service Code
|
HCPCS 77061 26,RT
|
| Hospital Charge Code |
5150413
|
|
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
|
|
|
DIGITAL BREAST TOMOSYNTHESIS UNILATERAL, RIGHT (NON-MEDICARE)
|
Facility
|
OP
|
$89.00
|
|
|
Service Code
|
HCPCS 77061 26,RT
|
| Hospital Charge Code |
5150413
|
|
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
|
|
|
DIGITAL BREAST TOMOSYNTHESIS UNILATERAL, RIGHT (NON-MEDICARE)
|
Facility
|
OP
|
$194.67
|
|
|
Service Code
|
HCPCS 77061 RT,TC
|
| Hospital Charge Code |
4150413
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$29.20 |
| Max. Negotiated Rate |
$489.00 |
| Rate for Payer: Aetna of NY Commercial |
$136.27
|
| Rate for Payer: Aetna of NY Medicare |
$89.55
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$77.87
|
| Rate for Payer: Cash Price |
$146.00
|
| Rate for Payer: Cash Price |
$146.00
|
| Rate for Payer: CDPHP Medicare |
$72.03
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$136.27
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$155.74
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$155.74
|
| Rate for Payer: EmblemHealth Medicaid |
$155.74
|
| Rate for Payer: EmblemHealth Medicare |
$66.19
|
| Rate for Payer: EmblemHealth Select Care |
$126.54
|
| Rate for Payer: Fidelis Medicare |
$77.87
|
| Rate for Payer: Galaxy Health Commercial |
$126.54
|
| Rate for Payer: Hamaspik Choice Medicare |
$77.87
|
| Rate for Payer: Humana Medicare |
$77.87
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$136.27
|
| Rate for Payer: Local 1199SEIU Medicare |
$89.55
|
| Rate for Payer: MVP Health Care of NY Commercial |
$146.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$109.60
|
| Rate for Payer: MVP Health Care of NY Medicare |
$81.76
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$489.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$29.20
|
| Rate for Payer: United Healthcare Commercial |
$489.00
|
| Rate for Payer: United Healthcare Medicare |
$77.87
|
| Rate for Payer: WellCare Medicare |
$107.07
|
|
|
DIGOXIN 0.125MG TABS 100 EA
|
Facility
|
OP
|
$26.78
|
|
|
Service Code
|
NDC 904592161
|
| Hospital Charge Code |
4400414
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.02 |
| Max. Negotiated Rate |
$21.42 |
| Rate for Payer: Aetna of NY Commercial |
$18.75
|
| Rate for Payer: Aetna of NY Medicare |
$12.32
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$10.71
|
| Rate for Payer: Cash Price |
$20.08
|
| Rate for Payer: CDPHP Medicare |
$9.91
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$21.42
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$21.42
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$21.42
|
| Rate for Payer: EmblemHealth Medicaid |
$21.42
|
| Rate for Payer: EmblemHealth Medicare |
$9.11
|
| Rate for Payer: EmblemHealth Select Care |
$19.28
|
| Rate for Payer: Fidelis Medicare |
$10.71
|
| Rate for Payer: Galaxy Health Commercial |
$17.41
|
| Rate for Payer: Hamaspik Choice Medicare |
$10.71
|
| Rate for Payer: Humana Medicare |
$10.71
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$18.75
|
| Rate for Payer: Local 1199SEIU Medicare |
$12.32
|
| Rate for Payer: MVP Health Care of NY Commercial |
$20.09
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$15.08
|
| Rate for Payer: MVP Health Care of NY Medicare |
$11.25
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$4.02
|
| Rate for Payer: United Healthcare Medicare |
$10.71
|
| Rate for Payer: WellCare Medicare |
$14.73
|
|
|
DIGOXIN 0.125MG TABS 100 EA
|
Facility
|
IP
|
$26.78
|
|
|
Service Code
|
NDC 904592161
|
| Hospital Charge Code |
4400414
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.73 |
| Max. Negotiated Rate |
$17.41 |
| Rate for Payer: Cash Price |
$20.08
|
| Rate for Payer: Galaxy Health Commercial |
$17.41
|
| Rate for Payer: WellCare Medicare |
$14.73
|
|
|
DIGOXIN IMMUNE FAB (OVINE) PER VIAL
|
Facility
|
OP
|
$10,849.51
|
|
|
Service Code
|
HCPCS J1162
|
| Hospital Charge Code |
4400229
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,627.43 |
| Max. Negotiated Rate |
$8,679.61 |
| Rate for Payer: Aetna of NY Medicare |
$4,990.77
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$4,339.80
|
| Rate for Payer: Cash Price |
$8,137.13
|
| Rate for Payer: Cash Price |
$8,137.13
|
| Rate for Payer: CDPHP Medicare |
$4,014.32
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$5,166.99
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$8,679.61
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$8,679.61
|
| Rate for Payer: EmblemHealth Medicaid |
$8,679.61
|
| Rate for Payer: EmblemHealth Medicare |
$3,688.83
|
| Rate for Payer: EmblemHealth Select Care |
$5,166.99
|
| Rate for Payer: Fidelis Medicare |
$4,339.80
|
| Rate for Payer: Galaxy Health Commercial |
$7,052.18
|
| Rate for Payer: Hamaspik Choice Medicare |
$4,339.80
|
| Rate for Payer: Humana Medicare |
$4,339.80
|
| Rate for Payer: Local 1199SEIU Medicare |
$4,990.77
|
| Rate for Payer: MVP Health Care of NY Commercial |
$8,137.13
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$6,108.27
|
| Rate for Payer: MVP Health Care of NY Medicare |
$4,556.79
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$7,579.39
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$1,627.43
|
| Rate for Payer: United Healthcare Commercial |
$7,579.39
|
| Rate for Payer: United Healthcare Medicare |
$4,339.80
|
| Rate for Payer: WellCare Medicare |
$5,967.23
|
|
|
DIGOXIN IMMUNE FAB (OVINE) PER VIAL
|
Facility
|
IP
|
$10,849.51
|
|
|
Service Code
|
HCPCS J1162
|
| Hospital Charge Code |
4400229
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5,166.99 |
| Max. Negotiated Rate |
$7,052.18 |
| Rate for Payer: Aetna of NY Commercial |
$5,967.23
|
| Rate for Payer: Cash Price |
$8,137.13
|
| Rate for Payer: Cash Price |
$8,137.13
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$5,166.99
|
| Rate for Payer: EmblemHealth Select Care |
$5,166.99
|
| Rate for Payer: Galaxy Health Commercial |
$7,052.18
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$5,967.23
|
| Rate for Payer: WellCare Medicare |
$5,967.23
|
|
|
DIGOXIN INJ, UP TO 0.5 MG
|
Facility
|
IP
|
$20.34
|
|
|
Service Code
|
HCPCS J1160
|
| Hospital Charge Code |
4408962
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.37 |
| Max. Negotiated Rate |
$13.22 |
| Rate for Payer: Aetna of NY Commercial |
$11.19
|
| Rate for Payer: Cash Price |
$15.26
|
| Rate for Payer: Cash Price |
$15.26
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$10.37
|
| Rate for Payer: EmblemHealth Select Care |
$10.37
|
| Rate for Payer: Galaxy Health Commercial |
$13.22
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$11.19
|
| Rate for Payer: WellCare Medicare |
$11.19
|
|
|
DIGOXIN INJ, UP TO 0.5 MG
|
Facility
|
OP
|
$20.34
|
|
|
Service Code
|
HCPCS J1160
|
| Hospital Charge Code |
4408962
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.05 |
| Max. Negotiated Rate |
$17.84 |
| Rate for Payer: Aetna of NY Medicare |
$9.36
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$8.14
|
| Rate for Payer: Cash Price |
$15.26
|
| Rate for Payer: Cash Price |
$15.26
|
| Rate for Payer: CDPHP Medicare |
$7.53
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$10.37
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$16.27
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$16.27
|
| Rate for Payer: EmblemHealth Medicaid |
$16.27
|
| Rate for Payer: EmblemHealth Medicare |
$6.92
|
| Rate for Payer: EmblemHealth Select Care |
$10.37
|
| Rate for Payer: Fidelis Medicare |
$8.14
|
| Rate for Payer: Galaxy Health Commercial |
$13.22
|
| Rate for Payer: Hamaspik Choice Medicare |
$8.14
|
| Rate for Payer: Humana Medicare |
$8.14
|
| Rate for Payer: Local 1199SEIU Medicare |
$9.36
|
| Rate for Payer: MVP Health Care of NY Commercial |
$15.26
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$11.45
|
| Rate for Payer: MVP Health Care of NY Medicare |
$8.54
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$17.84
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$3.05
|
| Rate for Payer: United Healthcare Commercial |
$17.84
|
| Rate for Payer: United Healthcare Medicare |
$8.14
|
| Rate for Payer: WellCare Medicare |
$11.19
|
|
|
DIGOXIN SERUM
|
Facility
|
OP
|
$40.00
|
|
|
Service Code
|
HCPCS 80162
|
| Hospital Charge Code |
4300271
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$6.00 |
| Max. Negotiated Rate |
$32.00 |
| Rate for Payer: Aetna of NY Commercial |
$26.00
|
| Rate for Payer: Aetna of NY Medicare |
$18.40
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$16.00
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: CDPHP Medicare |
$14.80
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$24.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$32.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$32.00
|
| Rate for Payer: EmblemHealth Medicaid |
$32.00
|
| Rate for Payer: EmblemHealth Medicare |
$13.60
|
| Rate for Payer: EmblemHealth Select Care |
$24.00
|
| Rate for Payer: Fidelis Medicare |
$16.00
|
| Rate for Payer: Galaxy Health Commercial |
$26.00
|
| Rate for Payer: Hamaspik Choice Medicare |
$16.00
|
| Rate for Payer: Humana Medicare |
$16.00
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$26.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$18.40
|
| Rate for Payer: MVP Health Care of NY Commercial |
$30.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$22.52
|
| Rate for Payer: MVP Health Care of NY Medicare |
$16.80
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$30.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$6.00
|
| Rate for Payer: United Healthcare Commercial |
$30.00
|
| Rate for Payer: United Healthcare Medicare |
$16.00
|
| Rate for Payer: WellCare Medicare |
$22.00
|
|
|
DIGOXIN SERUM
|
Facility
|
IP
|
$40.00
|
|
|
Service Code
|
HCPCS 80162
|
| Hospital Charge Code |
4300271
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$26.00 |
| Max. Negotiated Rate |
$26.00 |
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Galaxy Health Commercial |
$26.00
|
|
|
DILANTIN SERUM
|
Facility
|
IP
|
$51.00
|
|
|
Service Code
|
HCPCS 80185
|
| Hospital Charge Code |
4300272
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$33.15 |
| Max. Negotiated Rate |
$33.15 |
| Rate for Payer: Cash Price |
$38.25
|
| Rate for Payer: Galaxy Health Commercial |
$33.15
|
|
|
DILANTIN SERUM
|
Facility
|
OP
|
$51.00
|
|
|
Service Code
|
HCPCS 80185
|
| Hospital Charge Code |
4300272
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$7.65 |
| Max. Negotiated Rate |
$40.80 |
| Rate for Payer: Aetna of NY Commercial |
$33.15
|
| Rate for Payer: Aetna of NY Medicare |
$23.46
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$20.40
|
| Rate for Payer: Cash Price |
$38.25
|
| Rate for Payer: CDPHP Medicare |
$18.87
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$30.60
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$40.80
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$40.80
|
| Rate for Payer: EmblemHealth Medicaid |
$40.80
|
| Rate for Payer: EmblemHealth Medicare |
$17.34
|
| Rate for Payer: EmblemHealth Select Care |
$30.60
|
| Rate for Payer: Fidelis Medicare |
$20.40
|
| Rate for Payer: Galaxy Health Commercial |
$33.15
|
| Rate for Payer: Hamaspik Choice Medicare |
$20.40
|
| Rate for Payer: Humana Medicare |
$20.40
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$33.15
|
| Rate for Payer: Local 1199SEIU Medicare |
$23.46
|
| Rate for Payer: MVP Health Care of NY Commercial |
$38.25
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$28.71
|
| Rate for Payer: MVP Health Care of NY Medicare |
$21.42
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$38.25
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$7.65
|
| Rate for Payer: United Healthcare Commercial |
$38.25
|
| Rate for Payer: United Healthcare Medicare |
$20.40
|
| Rate for Payer: WellCare Medicare |
$28.05
|
|
|
DILAT FEMALE URETHRA GENERAL/CNDJ SPINAL ANES
|
Facility
|
OP
|
$6,407.00
|
|
|
Service Code
|
HCPCS 53665
|
| Hospital Charge Code |
4002038
|
|
Hospital Revenue Code
|
490
|
| Min. Negotiated Rate |
$961.05 |
| Max. Negotiated Rate |
$5,125.60 |
| Rate for Payer: Aetna of NY Commercial |
$1,900.00
|
| Rate for Payer: Aetna of NY Medicare |
$2,947.22
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$2,562.80
|
| Rate for Payer: Cash Price |
$4,805.25
|
| Rate for Payer: Cash Price |
$4,805.25
|
| Rate for Payer: CDPHP Medicare |
$2,370.59
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$5,125.60
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$5,125.60
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$5,125.60
|
| Rate for Payer: EmblemHealth Medicaid |
$5,125.60
|
| Rate for Payer: EmblemHealth Medicare |
$2,178.38
|
| Rate for Payer: EmblemHealth Select Care |
$4,613.04
|
| Rate for Payer: Fidelis Medicare |
$2,562.80
|
| Rate for Payer: Galaxy Health Commercial |
$4,164.55
|
| Rate for Payer: Hamaspik Choice Medicare |
$2,562.80
|
| Rate for Payer: Humana Medicare |
$2,562.80
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,900.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$2,947.22
|
| Rate for Payer: Multiplan Commercial |
$5,125.60
|
| Rate for Payer: MVP Health Care of NY Commercial |
$4,805.25
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$3,607.14
|
| Rate for Payer: MVP Health Care of NY Medicare |
$2,690.94
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$2,097.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$961.05
|
| Rate for Payer: United Healthcare Commercial |
$2,097.00
|
| Rate for Payer: United Healthcare Medicare |
$2,562.80
|
| Rate for Payer: WellCare Medicare |
$3,523.85
|
|
|
DILAT FEMALE URETHRA GENERAL/CNDJ SPINAL ANES
|
Facility
|
IP
|
$6,407.00
|
|
|
Service Code
|
HCPCS 53665
|
| Hospital Charge Code |
4002038
|
|
Hospital Revenue Code
|
490
|
| Min. Negotiated Rate |
$4,164.55 |
| Max. Negotiated Rate |
$4,164.55 |
| Rate for Payer: Cash Price |
$4,805.25
|
| Rate for Payer: Galaxy Health Commercial |
$4,164.55
|
|
|
DILAT FEMALE URETHRA W/SUPPOSITORY&/INSTLJ INI
|
Facility
|
IP
|
$469.00
|
|
|
Service Code
|
HCPCS 53660
|
| Hospital Charge Code |
4002037
|
|
Hospital Revenue Code
|
490
|
| Min. Negotiated Rate |
$304.85 |
| Max. Negotiated Rate |
$304.85 |
| Rate for Payer: Cash Price |
$351.75
|
| Rate for Payer: Galaxy Health Commercial |
$304.85
|
|
