|
FRESH FROZEN PLASMA
|
Facility
|
OP
|
$626.00
|
|
|
Service Code
|
HCPCS P9021
|
| Hospital Charge Code |
4304876
|
|
Hospital Revenue Code
|
390
|
| Min. Negotiated Rate |
$136.51 |
| Max. Negotiated Rate |
$503.93 |
| Rate for Payer: Aetna of NY Commercial |
$438.20
|
| Rate for Payer: Aetna of NY Medicare |
$287.96
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$469.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$469.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$231.62
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$313.00
|
| Rate for Payer: Cash Price |
$469.50
|
| Rate for Payer: Cash Price |
$469.50
|
| Rate for Payer: CDPHP Commercial |
$503.93
|
| Rate for Payer: CDPHP Medicare |
$231.62
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$313.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$500.80
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$500.80
|
| Rate for Payer: EmblemHealth Medicaid |
$500.80
|
| Rate for Payer: EmblemHealth Medicare |
$212.84
|
| Rate for Payer: EmblemHealth Select Care |
$313.00
|
| Rate for Payer: Fidelis Medicare |
$238.57
|
| Rate for Payer: Galaxy Health Commercial |
$406.90
|
| Rate for Payer: Hamaspik Choice Medicare |
$231.62
|
| Rate for Payer: Humana Medicare |
$231.62
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$438.20
|
| Rate for Payer: Local 1199SEIU Medicare |
$287.96
|
| Rate for Payer: MVP Health Care of NY Commercial |
$469.50
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$352.44
|
| Rate for Payer: MVP Health Care of NY Medicare |
$243.20
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$469.50
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$136.51
|
| Rate for Payer: United Healthcare Commercial |
$469.50
|
| Rate for Payer: United Healthcare Medicare |
$231.62
|
| Rate for Payer: WellCare Medicare |
$344.30
|
|
|
FUROSEMIDE 20MG TABS 10X10EA
|
Facility
|
IP
|
$6.18
|
|
|
Service Code
|
NDC 51079007201
|
| Hospital Charge Code |
4400312
|
|
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
|
|
|
FUROSEMIDE 20MG TABS 10X10EA
|
Facility
|
OP
|
$6.18
|
|
|
Service Code
|
NDC 51079007201
|
| Hospital Charge Code |
4400312
|
|
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
|
|
|
FUROSEMIDE 40 MG/4 ML VIAL 10 mg, 4 mL
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
HCPCS J1940
|
| Hospital Charge Code |
4401517
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.61 |
| 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 |
$0.61
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$0.61
|
| 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 |
$0.61
|
| 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 |
$0.61
|
| 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 |
$0.83
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$0.61
|
| Rate for Payer: United Healthcare Commercial |
$0.83
|
| Rate for Payer: United Healthcare Medicare |
$2.22
|
| Rate for Payer: WellCare Medicare |
$3.30
|
|
|
FUROSEMIDE 40 MG/4 ML VIAL 10 mg, 4 mL
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
HCPCS J1940
|
| Hospital Charge Code |
4401517
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.61 |
| 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 |
$0.61
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$0.61
|
| Rate for Payer: Cash Price |
$4.50
|
| Rate for Payer: Cash Price |
$4.50
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$0.61
|
| Rate for Payer: EmblemHealth Select Care |
$0.61
|
| 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
|
|
|
FUROSEMIDE 40MG TABS 100 EA
|
Facility
|
IP
|
$6.18
|
|
|
Service Code
|
NDC 00054829925
|
| Hospital Charge Code |
4400313
|
|
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
|
|
|
FUROSEMIDE 40MG TABS 100 EA
|
Facility
|
OP
|
$6.18
|
|
|
Service Code
|
NDC 00054829925
|
| Hospital Charge Code |
4400313
|
|
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
|
|
|
FUROSEMIDE INJ, UP TO 20 MG
|
Facility
|
OP
|
$18.80
|
|
|
Service Code
|
HCPCS J1940
|
| Hospital Charge Code |
4400311
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$15.13 |
| Rate for Payer: Aetna of NY Commercial |
$10.34
|
| Rate for Payer: Aetna of NY Medicare |
$8.65
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$0.61
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$0.61
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$6.96
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$9.40
|
| Rate for Payer: Cash Price |
$14.10
|
| Rate for Payer: Cash Price |
$14.10
|
| Rate for Payer: CDPHP Commercial |
$15.13
|
| Rate for Payer: CDPHP Medicare |
$6.96
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$0.61
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$15.04
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$15.04
|
| Rate for Payer: EmblemHealth Medicaid |
$15.04
|
| Rate for Payer: EmblemHealth Medicare |
$6.39
|
| Rate for Payer: EmblemHealth Select Care |
$0.61
|
| Rate for Payer: Fidelis Medicare |
$7.16
|
| Rate for Payer: Galaxy Health Commercial |
$12.22
|
| Rate for Payer: Hamaspik Choice Medicare |
$6.96
|
| Rate for Payer: Humana Medicare |
$6.96
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$10.34
|
| Rate for Payer: Local 1199SEIU Medicare |
$8.65
|
| Rate for Payer: MVP Health Care of NY Commercial |
$14.10
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$10.58
|
| Rate for Payer: MVP Health Care of NY Medicare |
$7.30
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$0.83
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$0.61
|
| Rate for Payer: United Healthcare Commercial |
$0.83
|
| Rate for Payer: United Healthcare Medicare |
$6.96
|
| Rate for Payer: WellCare Medicare |
$10.34
|
|
|
FUROSEMIDE INJ, UP TO 20 MG
|
Facility
|
IP
|
$18.80
|
|
|
Service Code
|
HCPCS J1940
|
| Hospital Charge Code |
4400311
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$12.22 |
| Rate for Payer: Aetna of NY Commercial |
$10.34
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$0.61
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$0.61
|
| Rate for Payer: Cash Price |
$14.10
|
| Rate for Payer: Cash Price |
$14.10
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$0.61
|
| Rate for Payer: EmblemHealth Select Care |
$0.61
|
| Rate for Payer: Galaxy Health Commercial |
$12.22
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$10.34
|
| Rate for Payer: WellCare Medicare |
$10.34
|
|
|
GABAPENTIN 100MG CAPS 10X10EA
|
Facility
|
OP
|
$6.18
|
|
|
Service Code
|
NDC 63739059110
|
| Hospital Charge Code |
4400315
|
|
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
|
|
|
GABAPENTIN 100MG CAPS 10X10EA
|
Facility
|
IP
|
$6.18
|
|
|
Service Code
|
NDC 63739059110
|
| Hospital Charge Code |
4400315
|
|
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
|
|
|
GABAPENTIN 300MG CAPS 10X10EA
|
Facility
|
OP
|
$6.18
|
|
|
Service Code
|
NDC 68084076211
|
| Hospital Charge Code |
4400317
|
|
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
|
|
|
GABAPENTIN 300MG CAPS 10X10EA
|
Facility
|
IP
|
$6.18
|
|
|
Service Code
|
NDC 68084076211
|
| Hospital Charge Code |
4400317
|
|
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
|
|
|
GABAPENTIN 400MG CAPS 10X10EA
|
Facility
|
OP
|
$7.25
|
|
|
Service Code
|
NDC 68084077411
|
| Hospital Charge Code |
4400316
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.46 |
| Max. Negotiated Rate |
$5.84 |
| Rate for Payer: Aetna of NY Commercial |
$5.08
|
| Rate for Payer: Aetna of NY Medicare |
$3.34
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$5.44
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$5.44
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$2.68
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$3.62
|
| Rate for Payer: Cash Price |
$5.44
|
| Rate for Payer: CDPHP Commercial |
$5.84
|
| Rate for Payer: CDPHP Medicare |
$2.68
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$5.80
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$5.80
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$5.80
|
| Rate for Payer: EmblemHealth Medicaid |
$5.80
|
| Rate for Payer: EmblemHealth Medicare |
$2.46
|
| Rate for Payer: EmblemHealth Select Care |
$5.22
|
| Rate for Payer: Fidelis Medicare |
$2.76
|
| Rate for Payer: Galaxy Health Commercial |
$4.71
|
| Rate for Payer: Hamaspik Choice Medicare |
$2.68
|
| Rate for Payer: Humana Medicare |
$2.68
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$5.08
|
| Rate for Payer: Local 1199SEIU Medicare |
$3.34
|
| Rate for Payer: MVP Health Care of NY Commercial |
$5.44
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$4.08
|
| Rate for Payer: MVP Health Care of NY Medicare |
$2.82
|
| Rate for Payer: United Healthcare Medicare |
$2.68
|
| Rate for Payer: WellCare Medicare |
$3.99
|
|
|
GABAPENTIN 400MG CAPS 10X10EA
|
Facility
|
IP
|
$7.25
|
|
|
Service Code
|
NDC 68084077411
|
| Hospital Charge Code |
4400316
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.99 |
| Max. Negotiated Rate |
$4.71 |
| Rate for Payer: Cash Price |
$5.44
|
| Rate for Payer: Galaxy Health Commercial |
$4.71
|
| Rate for Payer: WellCare Medicare |
$3.99
|
|
|
GAD-BASE MR CONTRAST NOS PER 1 ML (OPTIMARK)
|
Facility
|
OP
|
$291.00
|
|
|
Service Code
|
HCPCS A9579
|
| Hospital Charge Code |
4231000
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.51 |
| Max. Negotiated Rate |
$234.26 |
| Rate for Payer: Aetna of NY Commercial |
$160.05
|
| Rate for Payer: Aetna of NY Medicare |
$133.86
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$1.51
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$1.51
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$107.67
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$145.50
|
| Rate for Payer: Cash Price |
$218.25
|
| Rate for Payer: Cash Price |
$218.25
|
| Rate for Payer: CDPHP Commercial |
$234.26
|
| Rate for Payer: CDPHP Medicare |
$107.67
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$1.51
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$232.80
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$232.80
|
| Rate for Payer: EmblemHealth Medicaid |
$232.80
|
| Rate for Payer: EmblemHealth Medicare |
$98.94
|
| Rate for Payer: EmblemHealth Select Care |
$1.51
|
| Rate for Payer: Fidelis Medicare |
$110.90
|
| Rate for Payer: Galaxy Health Commercial |
$189.15
|
| Rate for Payer: Hamaspik Choice Medicare |
$107.67
|
| Rate for Payer: Humana Medicare |
$107.67
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$160.05
|
| Rate for Payer: Local 1199SEIU Medicare |
$133.86
|
| Rate for Payer: MVP Health Care of NY Commercial |
$218.25
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$163.83
|
| Rate for Payer: MVP Health Care of NY Medicare |
$113.05
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$2.56
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$1.51
|
| Rate for Payer: United Healthcare Commercial |
$2.56
|
| Rate for Payer: United Healthcare Medicare |
$107.67
|
| Rate for Payer: WellCare Medicare |
$160.05
|
|
|
GAD-BASE MR CONTRAST NOS PER 1 ML (OPTIMARK)
|
Facility
|
IP
|
$291.00
|
|
|
Service Code
|
HCPCS A9579
|
| Hospital Charge Code |
4231000
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.51 |
| Max. Negotiated Rate |
$189.15 |
| Rate for Payer: Aetna of NY Commercial |
$160.05
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$1.51
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$1.51
|
| Rate for Payer: Cash Price |
$218.25
|
| Rate for Payer: Cash Price |
$218.25
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$1.51
|
| Rate for Payer: EmblemHealth Select Care |
$1.51
|
| Rate for Payer: Galaxy Health Commercial |
$189.15
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$160.05
|
| Rate for Payer: WellCare Medicare |
$160.05
|
|
|
GALLIUM 67 (PER MCI)
|
Facility
|
OP
|
$67.00
|
|
|
Service Code
|
HCPCS A9556
|
| Hospital Charge Code |
4211243
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$22.64 |
| Max. Negotiated Rate |
$53.94 |
| Rate for Payer: Aetna of NY Medicare |
$30.82
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$50.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$50.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$24.79
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$33.50
|
| Rate for Payer: Cash Price |
$50.25
|
| Rate for Payer: Cash Price |
$50.25
|
| Rate for Payer: CDPHP Commercial |
$53.94
|
| Rate for Payer: CDPHP Medicare |
$24.79
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$53.60
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$53.60
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$53.60
|
| Rate for Payer: EmblemHealth Medicaid |
$53.60
|
| Rate for Payer: EmblemHealth Medicare |
$22.78
|
| Rate for Payer: EmblemHealth Select Care |
$48.24
|
| Rate for Payer: Fidelis Medicare |
$25.53
|
| Rate for Payer: Galaxy Health Commercial |
$43.55
|
| Rate for Payer: Hamaspik Choice Medicare |
$24.79
|
| Rate for Payer: Humana Medicare |
$24.79
|
| Rate for Payer: Local 1199SEIU Medicare |
$30.82
|
| Rate for Payer: MVP Health Care of NY Commercial |
$50.25
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$37.72
|
| Rate for Payer: MVP Health Care of NY Medicare |
$26.03
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$38.02
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$22.64
|
| Rate for Payer: United Healthcare Commercial |
$38.02
|
| Rate for Payer: United Healthcare Medicare |
$24.79
|
| Rate for Payer: WellCare Medicare |
$36.85
|
|
|
GALLIUM 67 (PER MCI)
|
Facility
|
IP
|
$67.00
|
|
|
Service Code
|
HCPCS A9556
|
| Hospital Charge Code |
4211243
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$43.55 |
| Max. Negotiated Rate |
$43.55 |
| Rate for Payer: Cash Price |
$50.25
|
| Rate for Payer: Galaxy Health Commercial |
$43.55
|
|
|
GAMMA GLUT TRANS (GGT)
|
Facility
|
IP
|
$39.00
|
|
|
Service Code
|
HCPCS 82977
|
| Hospital Charge Code |
4300365
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$25.35 |
| Max. Negotiated Rate |
$25.35 |
| Rate for Payer: Cash Price |
$29.25
|
| Rate for Payer: Galaxy Health Commercial |
$25.35
|
|
|
GAMMA GLUT TRANS (GGT)
|
Facility
|
OP
|
$39.00
|
|
|
Service Code
|
HCPCS 82977
|
| Hospital Charge Code |
4300365
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$5.08 |
| Max. Negotiated Rate |
$31.40 |
| Rate for Payer: Aetna of NY Commercial |
$25.35
|
| Rate for Payer: Aetna of NY Medicare |
$17.94
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$29.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$29.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$14.43
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$19.50
|
| Rate for Payer: Cash Price |
$29.25
|
| Rate for Payer: Cash Price |
$29.25
|
| Rate for Payer: CDPHP Commercial |
$31.40
|
| Rate for Payer: CDPHP Medicare |
$14.43
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$23.40
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$31.20
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$31.20
|
| Rate for Payer: EmblemHealth Medicaid |
$31.20
|
| Rate for Payer: EmblemHealth Medicare |
$13.26
|
| Rate for Payer: EmblemHealth Select Care |
$23.40
|
| Rate for Payer: Fidelis Medicare |
$14.86
|
| Rate for Payer: Galaxy Health Commercial |
$25.35
|
| Rate for Payer: Hamaspik Choice Medicare |
$14.43
|
| Rate for Payer: Humana Medicare |
$14.43
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$25.35
|
| Rate for Payer: Local 1199SEIU Medicare |
$17.94
|
| Rate for Payer: MVP Health Care of NY Commercial |
$29.25
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$21.96
|
| Rate for Payer: MVP Health Care of NY Medicare |
$15.15
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$29.25
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$5.08
|
| Rate for Payer: United Healthcare Commercial |
$29.25
|
| Rate for Payer: United Healthcare Medicare |
$14.43
|
| Rate for Payer: WellCare Medicare |
$21.45
|
|
|
GANGLION CYST INJ OR ASPIR
|
Facility
|
OP
|
$847.00
|
|
|
Service Code
|
HCPCS 20612
|
| Hospital Charge Code |
4850032
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$282.20 |
| Max. Negotiated Rate |
$2,521.93 |
| Rate for Payer: Aetna of NY Commercial |
$592.90
|
| Rate for Payer: Aetna of NY Medicare |
$389.62
|
| 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 |
$313.39
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$423.50
|
| Rate for Payer: Cash Price |
$635.25
|
| Rate for Payer: Cash Price |
$635.25
|
| Rate for Payer: Cash Price |
$635.25
|
| Rate for Payer: CDPHP Commercial |
$681.84
|
| Rate for Payer: CDPHP Medicare |
$313.39
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$677.60
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$677.60
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$677.60
|
| Rate for Payer: EmblemHealth Medicaid |
$677.60
|
| Rate for Payer: EmblemHealth Medicare |
$287.98
|
| Rate for Payer: EmblemHealth Select Care |
$609.84
|
| Rate for Payer: Fidelis Medicare |
$322.79
|
| Rate for Payer: Galaxy Health Commercial |
$550.55
|
| Rate for Payer: Hamaspik Choice Medicare |
$313.39
|
| Rate for Payer: Humana Medicare |
$313.39
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$592.90
|
| Rate for Payer: Local 1199SEIU Medicare |
$389.62
|
| Rate for Payer: MVP Health Care of NY Commercial |
$635.25
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$476.86
|
| Rate for Payer: MVP Health Care of NY Medicare |
$329.06
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$282.20
|
| Rate for Payer: United Healthcare Medicare |
$313.39
|
| Rate for Payer: WellCare Medicare |
$465.85
|
|
|
GANGLION CYST INJ OR ASPIR
|
Facility
|
IP
|
$847.00
|
|
|
Service Code
|
HCPCS 20612
|
| Hospital Charge Code |
4850032
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$550.55 |
| Max. Negotiated Rate |
$550.55 |
| Rate for Payer: Cash Price |
$635.25
|
| Rate for Payer: Galaxy Health Commercial |
$550.55
|
|
|
GARAMYCIN GENTAMICIN INJ, UP TO 80 MG
|
Facility
|
OP
|
$11.85
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
4400322
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.73 |
| Max. Negotiated Rate |
$9.54 |
| Rate for Payer: Aetna of NY Commercial |
$6.52
|
| Rate for Payer: Aetna of NY Medicare |
$5.45
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$2.73
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$2.73
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$4.38
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$5.92
|
| Rate for Payer: Cash Price |
$8.89
|
| Rate for Payer: Cash Price |
$8.89
|
| Rate for Payer: CDPHP Commercial |
$9.54
|
| Rate for Payer: CDPHP Medicare |
$4.38
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$2.73
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$9.48
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$9.48
|
| Rate for Payer: EmblemHealth Medicaid |
$9.48
|
| Rate for Payer: EmblemHealth Medicare |
$4.03
|
| Rate for Payer: EmblemHealth Select Care |
$2.73
|
| Rate for Payer: Fidelis Medicare |
$4.52
|
| Rate for Payer: Galaxy Health Commercial |
$7.70
|
| Rate for Payer: Hamaspik Choice Medicare |
$4.38
|
| Rate for Payer: Humana Medicare |
$4.38
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$6.52
|
| Rate for Payer: Local 1199SEIU Medicare |
$5.45
|
| Rate for Payer: MVP Health Care of NY Commercial |
$8.89
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$6.67
|
| Rate for Payer: MVP Health Care of NY Medicare |
$4.60
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$4.93
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$2.73
|
| Rate for Payer: United Healthcare Commercial |
$4.93
|
| Rate for Payer: United Healthcare Medicare |
$4.38
|
| Rate for Payer: WellCare Medicare |
$6.52
|
|
|
GARAMYCIN GENTAMICIN INJ, UP TO 80 MG
|
Facility
|
IP
|
$11.85
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
4400322
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.73 |
| Max. Negotiated Rate |
$7.70 |
| Rate for Payer: Aetna of NY Commercial |
$6.52
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$2.73
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$2.73
|
| Rate for Payer: Cash Price |
$8.89
|
| Rate for Payer: Cash Price |
$8.89
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$2.73
|
| Rate for Payer: EmblemHealth Select Care |
$2.73
|
| Rate for Payer: Galaxy Health Commercial |
$7.70
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$6.52
|
| Rate for Payer: WellCare Medicare |
$6.52
|
|
