|
DIPHENHYDRAMINE HCL 25MG CAPS 10X10EA
|
Facility
|
OP
|
$6.18
|
|
|
Service Code
|
NDC 904530661
|
| Hospital Charge Code |
4400241
|
|
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
|
|
|
DIPHENHYDRAMINE HCL 25MG CAPS 10X10EA
|
Facility
|
IP
|
$6.18
|
|
|
Service Code
|
NDC 904530661
|
| Hospital Charge Code |
4400241
|
|
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
|
|
|
DIPHENHYDRAMINE HCL, UP TO 50 MG
|
Facility
|
IP
|
$6.18
|
|
|
Service Code
|
HCPCS J1200
|
| Hospital Charge Code |
4400242
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.69 |
| Max. Negotiated Rate |
$4.02 |
| Rate for Payer: Aetna of NY Commercial |
$3.40
|
| Rate for Payer: Cash Price |
$4.64
|
| Rate for Payer: Cash Price |
$4.64
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$0.69
|
| Rate for Payer: EmblemHealth Select Care |
$0.69
|
| Rate for Payer: Galaxy Health Commercial |
$4.02
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$3.40
|
| Rate for Payer: WellCare Medicare |
$3.40
|
|
|
DIPHENHYDRAMINE HCL, UP TO 50 MG
|
Facility
|
OP
|
$6.18
|
|
|
Service Code
|
HCPCS J1200
|
| Hospital Charge Code |
4400242
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.69 |
| Max. Negotiated Rate |
$4.94 |
| 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: Cash Price |
$4.64
|
| Rate for Payer: CDPHP Medicare |
$2.29
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$0.69
|
| 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 |
$0.69
|
| 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 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: Oxford Health Plans Freedom/Liberty/Metro |
$1.75
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$0.93
|
| Rate for Payer: United Healthcare Commercial |
$1.75
|
| Rate for Payer: United Healthcare Medicare |
$2.47
|
| Rate for Payer: WellCare Medicare |
$3.40
|
|
|
DIPHENOXYLATE/ATROPINE 2.5-0.025MG TABS
|
Facility
|
OP
|
$6.18
|
|
|
Service Code
|
NDC 378041501
|
| Hospital Charge Code |
4400243
|
|
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
|
|
|
DIPHENOXYLATE/ATROPINE 2.5-0.025MG TABS
|
Facility
|
IP
|
$6.18
|
|
|
Service Code
|
NDC 378041501
|
| Hospital Charge Code |
4400243
|
|
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
|
|
|
DIPHTH PERTUSSIS(ADACEL)TET VAC SYRN 10X
|
Facility
|
OP
|
$141.88
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
4400110
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.28 |
| Max. Negotiated Rate |
$113.50 |
| Rate for Payer: Aetna of NY Commercial |
$78.03
|
| Rate for Payer: Aetna of NY Medicare |
$65.26
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$56.75
|
| Rate for Payer: Cash Price |
$106.41
|
| Rate for Payer: Cash Price |
$106.41
|
| Rate for Payer: CDPHP Medicare |
$52.50
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$39.48
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$113.50
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$113.50
|
| Rate for Payer: EmblemHealth Medicaid |
$113.50
|
| Rate for Payer: EmblemHealth Medicare |
$48.24
|
| Rate for Payer: EmblemHealth Select Care |
$39.48
|
| Rate for Payer: Fidelis Medicare |
$56.75
|
| Rate for Payer: Galaxy Health Commercial |
$92.22
|
| Rate for Payer: Hamaspik Choice Medicare |
$56.75
|
| Rate for Payer: Humana Medicare |
$56.75
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$78.03
|
| Rate for Payer: Local 1199SEIU Medicare |
$65.26
|
| Rate for Payer: MVP Health Care of NY Commercial |
$106.41
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$79.88
|
| Rate for Payer: MVP Health Care of NY Medicare |
$59.59
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$63.94
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$21.28
|
| Rate for Payer: United Healthcare Commercial |
$63.94
|
| Rate for Payer: United Healthcare Medicare |
$56.75
|
| Rate for Payer: WellCare Medicare |
$78.03
|
|
|
DIPHTH PERTUSSIS(ADACEL)TET VAC SYRN 10X
|
Facility
|
IP
|
$141.88
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
4400110
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$39.48 |
| Max. Negotiated Rate |
$92.22 |
| Rate for Payer: Aetna of NY Commercial |
$78.03
|
| Rate for Payer: Cash Price |
$106.41
|
| Rate for Payer: Cash Price |
$106.41
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$39.48
|
| Rate for Payer: EmblemHealth Select Care |
$39.48
|
| Rate for Payer: Galaxy Health Commercial |
$92.22
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$78.03
|
| Rate for Payer: WellCare Medicare |
$78.03
|
|
|
DIPYRIDAMOLE 25 MG TAB
|
Facility
|
OP
|
$6.18
|
|
|
Service Code
|
NDC 64980013301
|
| Hospital Charge Code |
4409110
|
|
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
|
|
|
DIPYRIDAMOLE 25 MG TAB
|
Facility
|
IP
|
$6.18
|
|
|
Service Code
|
NDC 64980013301
|
| Hospital Charge Code |
4409110
|
|
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
|
|
|
DIRECT LDL
|
Facility
|
IP
|
$32.00
|
|
|
Service Code
|
HCPCS 83721
|
| Hospital Charge Code |
4300273
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$20.80 |
| Max. Negotiated Rate |
$20.80 |
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: Galaxy Health Commercial |
$20.80
|
|
|
DIRECT LDL
|
Facility
|
OP
|
$32.00
|
|
|
Service Code
|
HCPCS 83721
|
| Hospital Charge Code |
4300273
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$4.80 |
| Max. Negotiated Rate |
$25.60 |
| Rate for Payer: Aetna of NY Commercial |
$20.80
|
| Rate for Payer: Aetna of NY Medicare |
$14.72
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$12.80
|
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: CDPHP Medicare |
$11.84
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$19.20
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$25.60
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$25.60
|
| Rate for Payer: EmblemHealth Medicaid |
$25.60
|
| Rate for Payer: EmblemHealth Medicare |
$10.88
|
| Rate for Payer: EmblemHealth Select Care |
$19.20
|
| Rate for Payer: Fidelis Medicare |
$12.80
|
| Rate for Payer: Galaxy Health Commercial |
$20.80
|
| Rate for Payer: Hamaspik Choice Medicare |
$12.80
|
| Rate for Payer: Humana Medicare |
$12.80
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$20.80
|
| Rate for Payer: Local 1199SEIU Medicare |
$14.72
|
| Rate for Payer: MVP Health Care of NY Commercial |
$24.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$18.02
|
| Rate for Payer: MVP Health Care of NY Medicare |
$13.44
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$24.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$4.80
|
| Rate for Payer: United Healthcare Commercial |
$24.00
|
| Rate for Payer: United Healthcare Medicare |
$12.80
|
| Rate for Payer: WellCare Medicare |
$17.60
|
|
|
DISP BIOPSY FORCEPS - SPIKED
|
Facility
|
IP
|
$37.08
|
|
| Hospital Charge Code |
4471833
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$24.10 |
| Max. Negotiated Rate |
$24.10 |
| Rate for Payer: Cash Price |
$27.81
|
| Rate for Payer: Galaxy Health Commercial |
$24.10
|
|
|
DISP BIOPSY FORCEPS - SPIKED
|
Facility
|
OP
|
$37.08
|
|
| Hospital Charge Code |
4471833
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$5.56 |
| Max. Negotiated Rate |
$29.66 |
| Rate for Payer: Aetna of NY Commercial |
$25.96
|
| Rate for Payer: Aetna of NY Medicare |
$17.06
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$14.83
|
| Rate for Payer: Cash Price |
$27.81
|
| Rate for Payer: CDPHP Medicare |
$13.72
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$29.66
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$29.66
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$29.66
|
| Rate for Payer: EmblemHealth Medicaid |
$29.66
|
| Rate for Payer: EmblemHealth Medicare |
$12.61
|
| Rate for Payer: EmblemHealth Select Care |
$26.70
|
| Rate for Payer: Fidelis Medicare |
$14.83
|
| Rate for Payer: Galaxy Health Commercial |
$24.10
|
| Rate for Payer: Hamaspik Choice Medicare |
$14.83
|
| Rate for Payer: Humana Medicare |
$14.83
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$25.96
|
| Rate for Payer: Local 1199SEIU Medicare |
$17.06
|
| Rate for Payer: MVP Health Care of NY Commercial |
$27.81
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$20.88
|
| Rate for Payer: MVP Health Care of NY Medicare |
$15.57
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$5.56
|
| Rate for Payer: United Healthcare Medicare |
$14.83
|
| Rate for Payer: WellCare Medicare |
$20.39
|
|
|
DISP DUAL-INCI FALOPE-RING BAND 8MM W T
|
Facility
|
OP
|
$950.69
|
|
| Hospital Charge Code |
4479084
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$142.60 |
| Max. Negotiated Rate |
$760.55 |
| Rate for Payer: Aetna of NY Commercial |
$665.48
|
| Rate for Payer: Aetna of NY Medicare |
$437.32
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$380.28
|
| Rate for Payer: Cash Price |
$713.02
|
| Rate for Payer: CDPHP Medicare |
$351.76
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$760.55
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$760.55
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$760.55
|
| Rate for Payer: EmblemHealth Medicaid |
$760.55
|
| Rate for Payer: EmblemHealth Medicare |
$323.23
|
| Rate for Payer: EmblemHealth Select Care |
$684.50
|
| Rate for Payer: Fidelis Medicare |
$380.28
|
| Rate for Payer: Galaxy Health Commercial |
$617.95
|
| Rate for Payer: Hamaspik Choice Medicare |
$380.28
|
| Rate for Payer: Humana Medicare |
$380.28
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$665.48
|
| Rate for Payer: Local 1199SEIU Medicare |
$437.32
|
| Rate for Payer: MVP Health Care of NY Commercial |
$713.02
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$535.24
|
| Rate for Payer: MVP Health Care of NY Medicare |
$399.29
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$142.60
|
| Rate for Payer: United Healthcare Medicare |
$380.28
|
| Rate for Payer: WellCare Medicare |
$522.88
|
|
|
DISP DUAL-INCI FALOPE-RING BAND 8MM W T
|
Facility
|
IP
|
$950.69
|
|
| Hospital Charge Code |
4479084
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$617.95 |
| Max. Negotiated Rate |
$617.95 |
| Rate for Payer: Cash Price |
$713.02
|
| Rate for Payer: Galaxy Health Commercial |
$617.95
|
|
|
DISP DUAL-INCI FALOPE-RING BAND W/O TRO
|
Facility
|
IP
|
$670.53
|
|
| Hospital Charge Code |
4479085
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$435.84 |
| Max. Negotiated Rate |
$435.84 |
| Rate for Payer: Cash Price |
$502.90
|
| Rate for Payer: Galaxy Health Commercial |
$435.84
|
|
|
DISP DUAL-INCI FALOPE-RING BAND W/O TRO
|
Facility
|
OP
|
$670.53
|
|
| Hospital Charge Code |
4479085
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$100.58 |
| Max. Negotiated Rate |
$536.42 |
| Rate for Payer: Aetna of NY Commercial |
$469.37
|
| Rate for Payer: Aetna of NY Medicare |
$308.44
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$268.21
|
| Rate for Payer: Cash Price |
$502.90
|
| Rate for Payer: CDPHP Medicare |
$248.10
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$536.42
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$536.42
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$536.42
|
| Rate for Payer: EmblemHealth Medicaid |
$536.42
|
| Rate for Payer: EmblemHealth Medicare |
$227.98
|
| Rate for Payer: EmblemHealth Select Care |
$482.78
|
| Rate for Payer: Fidelis Medicare |
$268.21
|
| Rate for Payer: Galaxy Health Commercial |
$435.84
|
| Rate for Payer: Hamaspik Choice Medicare |
$268.21
|
| Rate for Payer: Humana Medicare |
$268.21
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$469.37
|
| Rate for Payer: Local 1199SEIU Medicare |
$308.44
|
| Rate for Payer: MVP Health Care of NY Commercial |
$502.90
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$377.51
|
| Rate for Payer: MVP Health Care of NY Medicare |
$281.62
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$100.58
|
| Rate for Payer: United Healthcare Medicare |
$268.21
|
| Rate for Payer: WellCare Medicare |
$368.79
|
|
|
DISPERSIVE ELECTRODE: PMA-GP-BAY 4479209
|
Facility
|
IP
|
$357.41
|
|
| Hospital Charge Code |
4479209
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$232.32 |
| Max. Negotiated Rate |
$232.32 |
| Rate for Payer: Cash Price |
$268.06
|
| Rate for Payer: Galaxy Health Commercial |
$232.32
|
|
|
DISPERSIVE ELECTRODE: PMA-GP-BAY 4479209
|
Facility
|
OP
|
$357.41
|
|
| Hospital Charge Code |
4479209
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$53.61 |
| Max. Negotiated Rate |
$285.93 |
| Rate for Payer: Aetna of NY Commercial |
$250.19
|
| Rate for Payer: Aetna of NY Medicare |
$164.41
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$142.96
|
| Rate for Payer: Cash Price |
$268.06
|
| Rate for Payer: CDPHP Medicare |
$132.24
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$285.93
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$285.93
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$285.93
|
| Rate for Payer: EmblemHealth Medicaid |
$285.93
|
| Rate for Payer: EmblemHealth Medicare |
$121.52
|
| Rate for Payer: EmblemHealth Select Care |
$257.34
|
| Rate for Payer: Fidelis Medicare |
$142.96
|
| Rate for Payer: Galaxy Health Commercial |
$232.32
|
| Rate for Payer: Hamaspik Choice Medicare |
$142.96
|
| Rate for Payer: Humana Medicare |
$142.96
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$250.19
|
| Rate for Payer: Local 1199SEIU Medicare |
$164.41
|
| Rate for Payer: MVP Health Care of NY Commercial |
$268.06
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$201.22
|
| Rate for Payer: MVP Health Care of NY Medicare |
$150.11
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$53.61
|
| Rate for Payer: United Healthcare Medicare |
$142.96
|
| Rate for Payer: WellCare Medicare |
$196.58
|
|
|
DISP HIGH FLOW INSULFLATOR
|
Facility
|
OP
|
$54.59
|
|
| Hospital Charge Code |
4471447
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$8.19 |
| Max. Negotiated Rate |
$43.67 |
| Rate for Payer: Aetna of NY Commercial |
$38.21
|
| Rate for Payer: Aetna of NY Medicare |
$25.11
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$21.84
|
| Rate for Payer: Cash Price |
$40.94
|
| Rate for Payer: CDPHP Medicare |
$20.20
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$43.67
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$43.67
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$43.67
|
| Rate for Payer: EmblemHealth Medicaid |
$43.67
|
| Rate for Payer: EmblemHealth Medicare |
$18.56
|
| Rate for Payer: EmblemHealth Select Care |
$39.30
|
| Rate for Payer: Fidelis Medicare |
$21.84
|
| Rate for Payer: Galaxy Health Commercial |
$35.48
|
| Rate for Payer: Hamaspik Choice Medicare |
$21.84
|
| Rate for Payer: Humana Medicare |
$21.84
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$38.21
|
| Rate for Payer: Local 1199SEIU Medicare |
$25.11
|
| Rate for Payer: MVP Health Care of NY Commercial |
$40.94
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$30.73
|
| Rate for Payer: MVP Health Care of NY Medicare |
$22.93
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$8.19
|
| Rate for Payer: United Healthcare Medicare |
$21.84
|
| Rate for Payer: WellCare Medicare |
$30.02
|
|
|
DISP HIGH FLOW INSULFLATOR
|
Facility
|
IP
|
$54.59
|
|
| Hospital Charge Code |
4471447
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$35.48 |
| Max. Negotiated Rate |
$35.48 |
| Rate for Payer: Cash Price |
$40.94
|
| Rate for Payer: Galaxy Health Commercial |
$35.48
|
|
|
DISPOSABLE GAIT BELTS
|
Facility
|
OP
|
$15.45
|
|
| Hospital Charge Code |
4479203
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$2.32 |
| Max. Negotiated Rate |
$12.36 |
| Rate for Payer: Aetna of NY Commercial |
$10.81
|
| Rate for Payer: Aetna of NY Medicare |
$7.11
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$6.18
|
| Rate for Payer: Cash Price |
$11.59
|
| Rate for Payer: CDPHP Medicare |
$5.72
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$12.36
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$12.36
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$12.36
|
| Rate for Payer: EmblemHealth Medicaid |
$12.36
|
| Rate for Payer: EmblemHealth Medicare |
$5.25
|
| Rate for Payer: EmblemHealth Select Care |
$11.12
|
| Rate for Payer: Fidelis Medicare |
$6.18
|
| Rate for Payer: Galaxy Health Commercial |
$10.04
|
| Rate for Payer: Hamaspik Choice Medicare |
$6.18
|
| Rate for Payer: Humana Medicare |
$6.18
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$10.81
|
| Rate for Payer: Local 1199SEIU Medicare |
$7.11
|
| Rate for Payer: MVP Health Care of NY Commercial |
$11.59
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$8.70
|
| Rate for Payer: MVP Health Care of NY Medicare |
$6.49
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$2.32
|
| Rate for Payer: United Healthcare Medicare |
$6.18
|
| Rate for Payer: WellCare Medicare |
$8.50
|
|
|
DISPOSABLE GAIT BELTS
|
Facility
|
IP
|
$15.45
|
|
| Hospital Charge Code |
4479203
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$10.04 |
| Max. Negotiated Rate |
$10.04 |
| Rate for Payer: Cash Price |
$11.59
|
| Rate for Payer: Galaxy Health Commercial |
$10.04
|
|
|
DISPOSIBLE SCLEROTHERAPY NEEDL
|
Facility
|
IP
|
$110.21
|
|
| Hospital Charge Code |
4471000
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$71.64 |
| Max. Negotiated Rate |
$71.64 |
| Rate for Payer: Cash Price |
$82.66
|
| Rate for Payer: Galaxy Health Commercial |
$71.64
|
|
