|
SODIUM POLYSTYRENE SULFONATE PO POWD
|
Facility
|
OP
|
$0.90
|
|
|
Service Code
|
NDC 1070203615
|
| Hospital Charge Code |
1070203615
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$0.72 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.45
|
| Rate for Payer: Aetna Government |
$0.45
|
| Rate for Payer: Brighton Health Commercial |
$0.68
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.72
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.61
|
| Rate for Payer: EmblemHealth Commercial |
$0.45
|
| Rate for Payer: Group Health Inc Commercial |
$0.45
|
| Rate for Payer: Group Health Inc Medicare |
$0.32
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.45
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.45
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.59
|
|
|
SODIUM TETRADECYL SULFATE 1 % IV SOLN
|
Facility
|
IP
|
$46.88
|
|
|
Service Code
|
NDC 6745716200
|
| Hospital Charge Code |
6745716200
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$23.44 |
| Max. Negotiated Rate |
$23.44 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$23.44
|
|
|
SODIUM TETRADECYL SULFATE 1 % IV SOLN
|
Facility
|
OP
|
$46.88
|
|
|
Service Code
|
NDC 6745716202
|
| Hospital Charge Code |
6745716202
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$16.41 |
| Max. Negotiated Rate |
$37.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$25.78
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$23.44
|
| Rate for Payer: Aetna Government |
$23.44
|
| Rate for Payer: Brighton Health Commercial |
$35.16
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$37.50
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$31.88
|
| Rate for Payer: EmblemHealth Commercial |
$23.44
|
| Rate for Payer: Group Health Inc Commercial |
$23.44
|
| Rate for Payer: Group Health Inc Medicare |
$16.41
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$23.44
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$23.44
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$30.47
|
|
|
SODIUM TETRADECYL SULFATE 1 % IV SOLN
|
Facility
|
IP
|
$46.88
|
|
|
Service Code
|
NDC 6745716202
|
| Hospital Charge Code |
6745716202
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$23.44 |
| Max. Negotiated Rate |
$23.44 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$23.44
|
|
|
SODIUM TETRADECYL SULFATE 1 % IV SOLN
|
Facility
|
OP
|
$46.88
|
|
|
Service Code
|
NDC 6745716200
|
| Hospital Charge Code |
6745716200
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$16.41 |
| Max. Negotiated Rate |
$37.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$25.78
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$23.44
|
| Rate for Payer: Aetna Government |
$23.44
|
| Rate for Payer: Brighton Health Commercial |
$35.16
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$37.50
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$31.88
|
| Rate for Payer: EmblemHealth Commercial |
$23.44
|
| Rate for Payer: Group Health Inc Commercial |
$23.44
|
| Rate for Payer: Group Health Inc Medicare |
$16.41
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$23.44
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$23.44
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$30.47
|
|
|
SODIUM TETRADECYL SULFATE 3 % IV SOLN
|
Facility
|
OP
|
$46.88
|
|
|
Service Code
|
NDC 6745716302
|
| Hospital Charge Code |
6745716302
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$16.41 |
| Max. Negotiated Rate |
$37.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$25.78
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$23.44
|
| Rate for Payer: Aetna Government |
$23.44
|
| Rate for Payer: Brighton Health Commercial |
$35.16
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$37.50
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$31.88
|
| Rate for Payer: EmblemHealth Commercial |
$23.44
|
| Rate for Payer: Group Health Inc Commercial |
$23.44
|
| Rate for Payer: Group Health Inc Medicare |
$16.41
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$23.44
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$23.44
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$30.47
|
|
|
SODIUM TETRADECYL SULFATE 3 % IV SOLN
|
Facility
|
IP
|
$46.88
|
|
|
Service Code
|
NDC 6745716302
|
| Hospital Charge Code |
6745716302
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$23.44 |
| Max. Negotiated Rate |
$23.44 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$23.44
|
|
|
SODIUM THIOSULFATE 250 MG/ML IV SOLN
|
Facility
|
OP
|
$2.32
|
|
|
Service Code
|
NDC 6026770550
|
| Hospital Charge Code |
6026770550
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$0.81 |
| Max. Negotiated Rate |
$1.86 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.28
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.16
|
| Rate for Payer: Aetna Government |
$1.16
|
| Rate for Payer: Brighton Health Commercial |
$1.74
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.86
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.58
|
| Rate for Payer: EmblemHealth Commercial |
$1.16
|
| Rate for Payer: Group Health Inc Commercial |
$1.16
|
| Rate for Payer: Group Health Inc Medicare |
$0.81
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.16
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.16
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.51
|
|
|
SODIUM THIOSULFATE 250 MG/ML IV SOLN
|
Facility
|
IP
|
$2.32
|
|
|
Service Code
|
NDC 6026770550
|
| Hospital Charge Code |
6026770550
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$1.16 |
| Max. Negotiated Rate |
$1.16 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.16
|
|
|
SODIUM ZIRCONIUM CYCLOSILICATE 10 G PO PACK
|
Facility
|
IP
|
$32.82
|
|
|
Service Code
|
NDC 0310111001
|
| Hospital Charge Code |
0310111001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.41 |
| Max. Negotiated Rate |
$16.41 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$16.41
|
|
|
SODIUM ZIRCONIUM CYCLOSILICATE 10 G PO PACK
|
Facility
|
OP
|
$32.82
|
|
|
Service Code
|
NDC 0310111001
|
| Hospital Charge Code |
0310111001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.49 |
| Max. Negotiated Rate |
$26.26 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$18.05
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$16.41
|
| Rate for Payer: Aetna Government |
$16.41
|
| Rate for Payer: Brighton Health Commercial |
$24.61
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$26.26
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$22.32
|
| Rate for Payer: EmblemHealth Commercial |
$16.41
|
| Rate for Payer: Group Health Inc Commercial |
$16.41
|
| Rate for Payer: Group Health Inc Medicare |
$11.49
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$16.41
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$16.41
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$21.33
|
|
|
SODIUM ZIRCONIUM CYCLOSILICATE 10 G PO PACK
|
Facility
|
IP
|
$32.82
|
|
|
Service Code
|
NDC 0310111039
|
| Hospital Charge Code |
0310111039
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.41 |
| Max. Negotiated Rate |
$16.41 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$16.41
|
|
|
SODIUM ZIRCONIUM CYCLOSILICATE 10 G PO PACK
|
Facility
|
IP
|
$32.82
|
|
|
Service Code
|
NDC 0310111030
|
| Hospital Charge Code |
0310111030
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.41 |
| Max. Negotiated Rate |
$16.41 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$16.41
|
|
|
SODIUM ZIRCONIUM CYCLOSILICATE 10 G PO PACK
|
Facility
|
OP
|
$32.82
|
|
|
Service Code
|
NDC 0310111039
|
| Hospital Charge Code |
0310111039
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.49 |
| Max. Negotiated Rate |
$26.26 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$18.05
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$16.41
|
| Rate for Payer: Aetna Government |
$16.41
|
| Rate for Payer: Brighton Health Commercial |
$24.61
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$26.26
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$22.32
|
| Rate for Payer: EmblemHealth Commercial |
$16.41
|
| Rate for Payer: Group Health Inc Commercial |
$16.41
|
| Rate for Payer: Group Health Inc Medicare |
$11.49
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$16.41
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$16.41
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$21.33
|
|
|
SODIUM ZIRCONIUM CYCLOSILICATE 10 G PO PACK
|
Facility
|
OP
|
$32.82
|
|
|
Service Code
|
NDC 0310111030
|
| Hospital Charge Code |
0310111030
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.49 |
| Max. Negotiated Rate |
$26.26 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$18.05
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$16.41
|
| Rate for Payer: Aetna Government |
$16.41
|
| Rate for Payer: Brighton Health Commercial |
$24.61
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$26.26
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$22.32
|
| Rate for Payer: EmblemHealth Commercial |
$16.41
|
| Rate for Payer: Group Health Inc Commercial |
$16.41
|
| Rate for Payer: Group Health Inc Medicare |
$11.49
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$16.41
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$16.41
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$21.33
|
|
|
SOFOSBUVIR 400 MG PO TABS
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 6195815011
|
| Hospital Charge Code |
6195815011
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$0.50 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.50
|
|
|
SOFOSBUVIR 400 MG PO TABS
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 6195815011
|
| Hospital Charge Code |
6195815011
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$0.80 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.55
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.50
|
| Rate for Payer: Aetna Government |
$0.50
|
| Rate for Payer: Brighton Health Commercial |
$0.75
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.80
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.68
|
| Rate for Payer: EmblemHealth Commercial |
$0.50
|
| Rate for Payer: Group Health Inc Commercial |
$0.50
|
| Rate for Payer: Group Health Inc Medicare |
$0.35
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.65
|
|
|
SORBITOL 70 % SOLN
|
Facility
|
OP
|
$0.13
|
|
|
Service Code
|
NDC 4628750030
|
| Hospital Charge Code |
4628750030
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.10 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.07
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.07
|
| Rate for Payer: Aetna Government |
$0.07
|
| Rate for Payer: Brighton Health Commercial |
$0.10
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.10
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.09
|
| Rate for Payer: EmblemHealth Commercial |
$0.07
|
| Rate for Payer: Group Health Inc Commercial |
$0.07
|
| Rate for Payer: Group Health Inc Medicare |
$0.05
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.07
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.07
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.08
|
|
|
SORBITOL 70 % SOLN
|
Facility
|
IP
|
$0.13
|
|
|
Service Code
|
NDC 4628750030
|
| Hospital Charge Code |
4628750030
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.07
|
|
|
SOTALOL HCL 80 MG PO TABS
|
Facility
|
IP
|
$2.35
|
|
|
Service Code
|
NDC 6958484110
|
| Hospital Charge Code |
6958484110
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.17 |
| Max. Negotiated Rate |
$1.17 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.17
|
|
|
SOTALOL HCL 80 MG PO TABS
|
Facility
|
OP
|
$2.35
|
|
|
Service Code
|
NDC 6958484110
|
| Hospital Charge Code |
6958484110
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.82 |
| Max. Negotiated Rate |
$1.88 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.29
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.17
|
| Rate for Payer: Aetna Government |
$1.17
|
| Rate for Payer: Brighton Health Commercial |
$1.76
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.88
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.60
|
| Rate for Payer: EmblemHealth Commercial |
$1.17
|
| Rate for Payer: Group Health Inc Commercial |
$1.17
|
| Rate for Payer: Group Health Inc Medicare |
$0.82
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.17
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.17
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.53
|
|
|
SPEECH THERAPY AND EVALUATION
|
Facility
|
OP
|
$211.07
|
|
|
Service Code
|
EAPG 00272
|
| Min. Negotiated Rate |
$152.74 |
| Max. Negotiated Rate |
$211.07 |
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$152.74
|
| Rate for Payer: Healthfirst Commercial |
$211.07
|
|
|
SPINAL DIAGNOSES AND INJURIES
|
Facility
|
OP
|
$247.97
|
|
|
Service Code
|
EAPG 00520
|
| Min. Negotiated Rate |
$180.52 |
| Max. Negotiated Rate |
$247.97 |
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$180.52
|
| Rate for Payer: Healthfirst Commercial |
$247.97
|
|
|
Spinal disorders & injuries
|
Facility
|
IP
|
$46,366.27
|
|
|
Service Code
|
APR-DRG 0401
|
| Min. Negotiated Rate |
$8,971.00 |
| Max. Negotiated Rate |
$46,366.27 |
| Rate for Payer: Affinity Essential Plan 1&2 |
$46,366.27
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$46,366.27
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$20,607.23
|
| Rate for Payer: Amida Care Medicaid |
$20,607.23
|
| Rate for Payer: EmblemHealth Essential Plan 1&2 |
$46,366.27
|
| Rate for Payer: EmblemHealth Essential Plan 3&4 |
$20,607.23
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$20,607.23
|
| Rate for Payer: Fidelis Qualified Health Plan |
$24,728.68
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$20,607.23
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$20,607.23
|
| Rate for Payer: Healthfirst Commercial |
$15,128.00
|
| Rate for Payer: Healthfirst Essential Plan |
$46,366.27
|
| Rate for Payer: Healthfirst QHP |
$8,971.00
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$20,607.23
|
| Rate for Payer: SOMOS Essential |
$46,366.27
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$46,366.27
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$46,366.27
|
| Rate for Payer: United Healthcare Medicaid |
$20,607.23
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$20,607.23
|
|
|
Spinal disorders & injuries
|
Facility
|
IP
|
$54,604.24
|
|
|
Service Code
|
APR-DRG 0402
|
| Min. Negotiated Rate |
$11,718.00 |
| Max. Negotiated Rate |
$54,604.24 |
| Rate for Payer: Affinity Essential Plan 1&2 |
$54,604.24
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$54,604.24
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$24,268.55
|
| Rate for Payer: Amida Care Medicaid |
$24,268.55
|
| Rate for Payer: EmblemHealth Essential Plan 1&2 |
$54,604.24
|
| Rate for Payer: EmblemHealth Essential Plan 3&4 |
$24,268.55
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$24,268.55
|
| Rate for Payer: Fidelis Qualified Health Plan |
$29,122.26
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$24,268.55
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$24,268.55
|
| Rate for Payer: Healthfirst Commercial |
$18,208.00
|
| Rate for Payer: Healthfirst Essential Plan |
$54,604.24
|
| Rate for Payer: Healthfirst QHP |
$11,718.00
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$24,268.55
|
| Rate for Payer: SOMOS Essential |
$54,604.24
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$54,604.24
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$54,604.24
|
| Rate for Payer: United Healthcare Medicaid |
$24,268.55
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$24,268.55
|
|
