|
FEVERALL 80 MG SUPPOSITORY 80 mg, 6 eaches
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
NDC 51672211402
|
| Hospital Charge Code |
4401544
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.30 |
| Max. Negotiated Rate |
$3.90 |
| Rate for Payer: Cash Price |
$4.50
|
| Rate for Payer: Galaxy Health Commercial |
$3.90
|
| Rate for Payer: WellCare Medicare |
$3.30
|
|
|
FIBERSTITCH (AR-4580S)
|
Facility
|
OP
|
$1,650.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4473045
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$247.50 |
| Max. Negotiated Rate |
$1,320.00 |
| Rate for Payer: Aetna of NY Commercial |
$1,155.00
|
| Rate for Payer: Aetna of NY Medicare |
$759.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$660.00
|
| Rate for Payer: Cash Price |
$1,237.50
|
| Rate for Payer: CDPHP Medicare |
$610.50
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$825.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$1,320.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$1,320.00
|
| Rate for Payer: EmblemHealth Medicaid |
$1,320.00
|
| Rate for Payer: EmblemHealth Medicare |
$561.00
|
| Rate for Payer: EmblemHealth Select Care |
$825.00
|
| Rate for Payer: Fidelis Medicare |
$660.00
|
| Rate for Payer: Galaxy Health Commercial |
$1,072.50
|
| Rate for Payer: Hamaspik Choice Medicare |
$660.00
|
| Rate for Payer: Humana Medicare |
$660.00
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,155.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$759.00
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,072.50
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$1,072.50
|
| Rate for Payer: MVP Health Care of NY Medicare |
$693.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$247.50
|
| Rate for Payer: United Healthcare Medicare |
$660.00
|
| Rate for Payer: WellCare Medicare |
$907.50
|
|
|
FIBERSTITCH (AR-4580S)
|
Facility
|
IP
|
$1,650.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4473045
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$742.50 |
| Max. Negotiated Rate |
$1,155.00 |
| Rate for Payer: Aetna of NY Commercial |
$1,155.00
|
| Rate for Payer: Cash Price |
$1,237.50
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$825.00
|
| Rate for Payer: EmblemHealth Select Care |
$825.00
|
| Rate for Payer: Galaxy Health Commercial |
$1,072.50
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,155.00
|
| Rate for Payer: Multiplan Commercial |
$742.50
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,072.50
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$1,072.50
|
| Rate for Payer: WellCare Medicare |
$907.50
|
|
|
FINASTERIDE 5MG TABS 10X10EA
|
Facility
|
OP
|
$10.30
|
|
|
Service Code
|
NDC 904683006
|
| Hospital Charge Code |
4400295
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.54 |
| Max. Negotiated Rate |
$8.24 |
| Rate for Payer: Aetna of NY Commercial |
$7.21
|
| Rate for Payer: Aetna of NY Medicare |
$4.74
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$4.12
|
| Rate for Payer: Cash Price |
$7.72
|
| Rate for Payer: CDPHP Medicare |
$3.81
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$8.24
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$8.24
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$8.24
|
| Rate for Payer: EmblemHealth Medicaid |
$8.24
|
| Rate for Payer: EmblemHealth Medicare |
$3.50
|
| Rate for Payer: EmblemHealth Select Care |
$7.42
|
| Rate for Payer: Fidelis Medicare |
$4.12
|
| Rate for Payer: Galaxy Health Commercial |
$6.70
|
| Rate for Payer: Hamaspik Choice Medicare |
$4.12
|
| Rate for Payer: Humana Medicare |
$4.12
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$7.21
|
| Rate for Payer: Local 1199SEIU Medicare |
$4.74
|
| Rate for Payer: MVP Health Care of NY Commercial |
$7.72
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$5.80
|
| Rate for Payer: MVP Health Care of NY Medicare |
$4.33
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$1.54
|
| Rate for Payer: United Healthcare Medicare |
$4.12
|
| Rate for Payer: WellCare Medicare |
$5.67
|
|
|
FINASTERIDE 5MG TABS 10X10EA
|
Facility
|
IP
|
$10.30
|
|
|
Service Code
|
NDC 904683006
|
| Hospital Charge Code |
4400295
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.67 |
| Max. Negotiated Rate |
$6.70 |
| Rate for Payer: Cash Price |
$7.72
|
| Rate for Payer: Galaxy Health Commercial |
$6.70
|
| Rate for Payer: WellCare Medicare |
$5.67
|
|
|
FINE NEEDLE ASPIRATION BX W/US GDN 1ST LEGION
|
Facility
|
IP
|
$227.00
|
|
|
Service Code
|
HCPCS 10005 26
|
| Hospital Charge Code |
5201074
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$147.55 |
| Max. Negotiated Rate |
$147.55 |
| Rate for Payer: Cash Price |
$170.25
|
| Rate for Payer: Galaxy Health Commercial |
$147.55
|
|
|
FINE NEEDLE ASPIRATION BX W/US GDN 1ST LEGION
|
Facility
|
OP
|
$227.00
|
|
|
Service Code
|
HCPCS 10005 26
|
| Hospital Charge Code |
5201074
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$34.05 |
| Max. Negotiated Rate |
$181.60 |
| Rate for Payer: Aetna of NY Commercial |
$158.90
|
| Rate for Payer: Aetna of NY Medicare |
$104.42
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$90.80
|
| Rate for Payer: Cash Price |
$170.25
|
| Rate for Payer: CDPHP Medicare |
$83.99
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$181.60
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$181.60
|
| Rate for Payer: EmblemHealth Medicaid |
$181.60
|
| Rate for Payer: EmblemHealth Medicare |
$77.18
|
| Rate for Payer: Fidelis Medicare |
$90.80
|
| Rate for Payer: Galaxy Health Commercial |
$147.55
|
| Rate for Payer: Hamaspik Choice Medicare |
$90.80
|
| Rate for Payer: Humana Medicare |
$90.80
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$158.90
|
| Rate for Payer: Local 1199SEIU Medicare |
$104.42
|
| Rate for Payer: MVP Health Care of NY Commercial |
$170.25
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$127.80
|
| Rate for Payer: MVP Health Care of NY Medicare |
$95.34
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$34.05
|
| Rate for Payer: United Healthcare Medicare |
$90.80
|
| Rate for Payer: WellCare Medicare |
$124.85
|
|
|
FINE NEEDLE ASPIRATION BX W/US GDN 1ST LESION
|
Facility
|
IP
|
$2,170.00
|
|
|
Service Code
|
HCPCS 10005
|
| Hospital Charge Code |
4201074
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$1,410.50 |
| Max. Negotiated Rate |
$1,410.50 |
| Rate for Payer: Cash Price |
$1,627.50
|
| Rate for Payer: Galaxy Health Commercial |
$1,410.50
|
|
|
FINE NEEDLE ASPIRATION BX W/US GDN 1ST LESION
|
Facility
|
OP
|
$2,170.00
|
|
|
Service Code
|
HCPCS 10005
|
| Hospital Charge Code |
4201074
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$325.50 |
| Max. Negotiated Rate |
$1,736.00 |
| Rate for Payer: Aetna of NY Commercial |
$1,519.00
|
| Rate for Payer: Aetna of NY Medicare |
$998.20
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$868.00
|
| Rate for Payer: Cash Price |
$1,627.50
|
| Rate for Payer: Cash Price |
$1,627.50
|
| Rate for Payer: CDPHP Medicare |
$802.90
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$1,519.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$1,736.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$1,736.00
|
| Rate for Payer: EmblemHealth Medicaid |
$1,736.00
|
| Rate for Payer: EmblemHealth Medicare |
$737.80
|
| Rate for Payer: EmblemHealth Select Care |
$1,410.50
|
| Rate for Payer: Fidelis Medicare |
$868.00
|
| Rate for Payer: Galaxy Health Commercial |
$1,410.50
|
| Rate for Payer: Hamaspik Choice Medicare |
$868.00
|
| Rate for Payer: Humana Medicare |
$868.00
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,519.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$998.20
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,627.50
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$1,221.71
|
| Rate for Payer: MVP Health Care of NY Medicare |
$911.40
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$489.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$325.50
|
| Rate for Payer: United Healthcare Commercial |
$489.00
|
| Rate for Payer: United Healthcare Medicare |
$868.00
|
| Rate for Payer: WellCare Medicare |
$1,193.50
|
|
|
FINE NEEDLE ASPIRATION BX W/US GDN EA ADDL
|
Facility
|
IP
|
$155.00
|
|
|
Service Code
|
HCPCS 10006 26
|
| Hospital Charge Code |
5201092
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$100.75 |
| Max. Negotiated Rate |
$100.75 |
| Rate for Payer: Cash Price |
$116.25
|
| Rate for Payer: Galaxy Health Commercial |
$100.75
|
|
|
FINE NEEDLE ASPIRATION BX W/US GDN EA ADDL
|
Facility
|
OP
|
$155.00
|
|
|
Service Code
|
HCPCS 10006 26
|
| Hospital Charge Code |
5201092
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$23.25 |
| Max. Negotiated Rate |
$124.00 |
| Rate for Payer: Aetna of NY Commercial |
$108.50
|
| Rate for Payer: Aetna of NY Medicare |
$71.30
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$62.00
|
| Rate for Payer: Cash Price |
$116.25
|
| Rate for Payer: CDPHP Medicare |
$57.35
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$124.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$124.00
|
| Rate for Payer: EmblemHealth Medicaid |
$124.00
|
| Rate for Payer: EmblemHealth Medicare |
$52.70
|
| Rate for Payer: Fidelis Medicare |
$62.00
|
| Rate for Payer: Galaxy Health Commercial |
$100.75
|
| Rate for Payer: Hamaspik Choice Medicare |
$62.00
|
| Rate for Payer: Humana Medicare |
$62.00
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$108.50
|
| Rate for Payer: Local 1199SEIU Medicare |
$71.30
|
| Rate for Payer: MVP Health Care of NY Commercial |
$116.25
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$87.27
|
| Rate for Payer: MVP Health Care of NY Medicare |
$65.10
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$23.25
|
| Rate for Payer: United Healthcare Medicare |
$62.00
|
| Rate for Payer: WellCare Medicare |
$85.25
|
|
|
FINE NEEDLE ASPIRATION BX W/US GDN EA ADDL,
|
Facility
|
OP
|
$195.00
|
|
|
Service Code
|
HCPCS 10006
|
| Hospital Charge Code |
4201092
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$29.25 |
| Max. Negotiated Rate |
$489.00 |
| Rate for Payer: Aetna of NY Commercial |
$136.50
|
| Rate for Payer: Aetna of NY Medicare |
$89.70
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$78.00
|
| Rate for Payer: Cash Price |
$146.25
|
| Rate for Payer: Cash Price |
$146.25
|
| Rate for Payer: CDPHP Medicare |
$72.15
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$136.50
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$156.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$156.00
|
| Rate for Payer: EmblemHealth Medicaid |
$156.00
|
| Rate for Payer: EmblemHealth Medicare |
$66.30
|
| Rate for Payer: EmblemHealth Select Care |
$126.75
|
| Rate for Payer: Fidelis Medicare |
$78.00
|
| Rate for Payer: Galaxy Health Commercial |
$126.75
|
| Rate for Payer: Hamaspik Choice Medicare |
$78.00
|
| Rate for Payer: Humana Medicare |
$78.00
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$136.50
|
| Rate for Payer: Local 1199SEIU Medicare |
$89.70
|
| Rate for Payer: MVP Health Care of NY Commercial |
$146.25
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$109.78
|
| Rate for Payer: MVP Health Care of NY Medicare |
$81.90
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$489.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$29.25
|
| Rate for Payer: United Healthcare Commercial |
$489.00
|
| Rate for Payer: United Healthcare Medicare |
$78.00
|
| Rate for Payer: WellCare Medicare |
$107.25
|
|
|
FINE NEEDLE ASPIRATION BX W/US GDN EA ADDL,
|
Facility
|
IP
|
$195.00
|
|
|
Service Code
|
HCPCS 10006
|
| Hospital Charge Code |
4201092
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$126.75 |
| Max. Negotiated Rate |
$126.75 |
| Rate for Payer: Cash Price |
$146.25
|
| Rate for Payer: Galaxy Health Commercial |
$126.75
|
|
|
FINGER ORTHOTIC, WITHOUT JOINTS, CUSTOM FABRICATED
|
Facility
|
IP
|
$610.79
|
|
|
Service Code
|
HCPCS L3933
|
| Hospital Charge Code |
4473011
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$274.86 |
| Max. Negotiated Rate |
$397.01 |
| Rate for Payer: Cash Price |
$458.09
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$305.39
|
| Rate for Payer: EmblemHealth Select Care |
$305.39
|
| Rate for Payer: Galaxy Health Commercial |
$397.01
|
| Rate for Payer: Multiplan Commercial |
$274.86
|
| Rate for Payer: WellCare Medicare |
$335.93
|
|
|
FINGER ORTHOTIC, WITHOUT JOINTS, CUSTOM FABRICATED
|
Facility
|
OP
|
$610.79
|
|
|
Service Code
|
HCPCS L3933
|
| Hospital Charge Code |
4473011
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$91.62 |
| Max. Negotiated Rate |
$488.63 |
| Rate for Payer: Aetna of NY Commercial |
$427.55
|
| Rate for Payer: Aetna of NY Medicare |
$280.96
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$244.32
|
| Rate for Payer: Cash Price |
$458.09
|
| Rate for Payer: CDPHP Medicare |
$225.99
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$305.39
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$488.63
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$488.63
|
| Rate for Payer: EmblemHealth Medicaid |
$488.63
|
| Rate for Payer: EmblemHealth Medicare |
$207.67
|
| Rate for Payer: EmblemHealth Select Care |
$305.39
|
| Rate for Payer: Fidelis Medicare |
$244.32
|
| Rate for Payer: Galaxy Health Commercial |
$397.01
|
| Rate for Payer: Hamaspik Choice Medicare |
$244.32
|
| Rate for Payer: Humana Medicare |
$244.32
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$427.55
|
| Rate for Payer: Local 1199SEIU Medicare |
$280.96
|
| Rate for Payer: MVP Health Care of NY Commercial |
$458.09
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$343.87
|
| Rate for Payer: MVP Health Care of NY Medicare |
$256.53
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$91.62
|
| Rate for Payer: United Healthcare Medicare |
$244.32
|
| Rate for Payer: WellCare Medicare |
$335.93
|
|
|
FINGER SPLINT APPLICATION
|
Facility
|
OP
|
$181.00
|
|
|
Service Code
|
HCPCS 29131
|
| Hospital Charge Code |
4850022
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$27.15 |
| Max. Negotiated Rate |
$1,234.00 |
| Rate for Payer: Aetna of NY Commercial |
$1,000.00
|
| Rate for Payer: Aetna of NY Medicare |
$83.26
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$72.40
|
| Rate for Payer: Cash Price |
$135.75
|
| Rate for Payer: Cash Price |
$135.75
|
| Rate for Payer: Cash Price |
$135.75
|
| Rate for Payer: CDPHP Medicare |
$66.97
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$1,206.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$144.80
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$144.80
|
| Rate for Payer: EmblemHealth Medicaid |
$144.80
|
| Rate for Payer: EmblemHealth Medicare |
$61.54
|
| Rate for Payer: EmblemHealth Select Care |
$1,085.00
|
| Rate for Payer: Fidelis Medicare |
$72.40
|
| Rate for Payer: Galaxy Health Commercial |
$117.65
|
| Rate for Payer: Hamaspik Choice Medicare |
$72.40
|
| Rate for Payer: Humana Medicare |
$72.40
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,000.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$83.26
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,234.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$925.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$76.02
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$1,009.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$27.15
|
| Rate for Payer: United Healthcare Commercial |
$1,009.00
|
| Rate for Payer: United Healthcare Medicare |
$72.40
|
| Rate for Payer: WellCare Medicare |
$99.55
|
|
|
FINGER SPLINT APPLICATION
|
Facility
|
IP
|
$181.00
|
|
|
Service Code
|
HCPCS 29131
|
| Hospital Charge Code |
4850022
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$117.65 |
| Max. Negotiated Rate |
$117.65 |
| Rate for Payer: Cash Price |
$135.75
|
| Rate for Payer: Galaxy Health Commercial |
$117.65
|
|
|
FIRST FRACTURE KIT 10/2
|
Facility
|
IP
|
$15,300.65
|
|
| Hospital Charge Code |
4478250
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,885.29 |
| Max. Negotiated Rate |
$10,710.45 |
| Rate for Payer: Aetna of NY Commercial |
$10,710.45
|
| Rate for Payer: Cash Price |
$11,475.49
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$7,650.32
|
| Rate for Payer: EmblemHealth Select Care |
$7,650.32
|
| Rate for Payer: Galaxy Health Commercial |
$9,945.42
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$10,710.45
|
| Rate for Payer: Multiplan Commercial |
$6,885.29
|
| Rate for Payer: MVP Health Care of NY Commercial |
$9,945.42
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$9,945.42
|
| Rate for Payer: WellCare Medicare |
$8,415.36
|
|
|
FIRST FRACTURE KIT 10/2
|
Facility
|
OP
|
$15,300.65
|
|
| Hospital Charge Code |
4478250
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,295.10 |
| Max. Negotiated Rate |
$12,240.52 |
| Rate for Payer: Aetna of NY Commercial |
$10,710.45
|
| Rate for Payer: Aetna of NY Medicare |
$7,038.30
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$6,120.26
|
| Rate for Payer: Cash Price |
$11,475.49
|
| Rate for Payer: CDPHP Medicare |
$5,661.24
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$7,650.32
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$12,240.52
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$12,240.52
|
| Rate for Payer: EmblemHealth Medicaid |
$12,240.52
|
| Rate for Payer: EmblemHealth Medicare |
$5,202.22
|
| Rate for Payer: EmblemHealth Select Care |
$7,650.32
|
| Rate for Payer: Fidelis Medicare |
$6,120.26
|
| Rate for Payer: Galaxy Health Commercial |
$9,945.42
|
| Rate for Payer: Hamaspik Choice Medicare |
$6,120.26
|
| Rate for Payer: Humana Medicare |
$6,120.26
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$10,710.45
|
| Rate for Payer: Local 1199SEIU Medicare |
$7,038.30
|
| Rate for Payer: MVP Health Care of NY Commercial |
$9,945.42
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$9,945.42
|
| Rate for Payer: MVP Health Care of NY Medicare |
$6,426.27
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$2,295.10
|
| Rate for Payer: United Healthcare Medicare |
$6,120.26
|
| Rate for Payer: WellCare Medicare |
$8,415.36
|
|
|
First Mouth Wash BLM Kit
|
Facility
|
OP
|
$270.00
|
|
|
Service Code
|
NDC 2
|
| Hospital Charge Code |
4401939
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$40.50 |
| Max. Negotiated Rate |
$216.00 |
| Rate for Payer: Aetna of NY Commercial |
$189.00
|
| Rate for Payer: Aetna of NY Medicare |
$124.20
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$108.00
|
| Rate for Payer: Cash Price |
$202.50
|
| Rate for Payer: CDPHP Medicare |
$99.90
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$216.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$216.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$216.00
|
| Rate for Payer: EmblemHealth Medicaid |
$216.00
|
| Rate for Payer: EmblemHealth Medicare |
$91.80
|
| Rate for Payer: EmblemHealth Select Care |
$194.40
|
| Rate for Payer: Fidelis Medicare |
$108.00
|
| Rate for Payer: Galaxy Health Commercial |
$175.50
|
| Rate for Payer: Hamaspik Choice Medicare |
$108.00
|
| Rate for Payer: Humana Medicare |
$108.00
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$189.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$124.20
|
| Rate for Payer: MVP Health Care of NY Commercial |
$202.50
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$152.01
|
| Rate for Payer: MVP Health Care of NY Medicare |
$113.40
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$40.50
|
| Rate for Payer: United Healthcare Medicare |
$108.00
|
| Rate for Payer: WellCare Medicare |
$148.50
|
|
|
First Mouth Wash BLM Kit
|
Facility
|
IP
|
$270.00
|
|
|
Service Code
|
NDC 2
|
| Hospital Charge Code |
4401939
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$148.50 |
| Max. Negotiated Rate |
$175.50 |
| Rate for Payer: Cash Price |
$202.50
|
| Rate for Payer: Galaxy Health Commercial |
$175.50
|
| Rate for Payer: WellCare Medicare |
$148.50
|
|
|
FISH OIL 1000MG GCAP 160+20EA
|
Facility
|
IP
|
$6.18
|
|
| Hospital Charge Code |
4400585
|
|
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
|
|
|
FISH OIL 1000MG GCAP 160+20EA
|
Facility
|
OP
|
$6.18
|
|
| Hospital Charge Code |
4400585
|
|
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
|
|
|
FLECAINIDE ACETATE 100 MG TAB 100 mg, 60 eaches
|
Facility
|
IP
|
$11.00
|
|
|
Service Code
|
NDC 54001121
|
| Hospital Charge Code |
4401540
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.05 |
| Max. Negotiated Rate |
$7.15 |
| Rate for Payer: Cash Price |
$8.25
|
| Rate for Payer: Galaxy Health Commercial |
$7.15
|
| Rate for Payer: WellCare Medicare |
$6.05
|
|
|
FLECAINIDE ACETATE 100 MG TAB 100 mg, 60 eaches
|
Facility
|
OP
|
$11.00
|
|
|
Service Code
|
NDC 54001121
|
| Hospital Charge Code |
4401540
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.65 |
| Max. Negotiated Rate |
$8.80 |
| Rate for Payer: Aetna of NY Commercial |
$7.70
|
| Rate for Payer: Aetna of NY Medicare |
$5.06
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$4.40
|
| Rate for Payer: Cash Price |
$8.25
|
| Rate for Payer: CDPHP Medicare |
$4.07
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$8.80
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$8.80
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$8.80
|
| Rate for Payer: EmblemHealth Medicaid |
$8.80
|
| Rate for Payer: EmblemHealth Medicare |
$3.74
|
| Rate for Payer: EmblemHealth Select Care |
$7.92
|
| Rate for Payer: Fidelis Medicare |
$4.40
|
| Rate for Payer: Galaxy Health Commercial |
$7.15
|
| Rate for Payer: Hamaspik Choice Medicare |
$4.40
|
| Rate for Payer: Humana Medicare |
$4.40
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$7.70
|
| Rate for Payer: Local 1199SEIU Medicare |
$5.06
|
| Rate for Payer: MVP Health Care of NY Commercial |
$8.25
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$6.19
|
| Rate for Payer: MVP Health Care of NY Medicare |
$4.62
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$1.65
|
| Rate for Payer: United Healthcare Medicare |
$4.40
|
| Rate for Payer: WellCare Medicare |
$6.05
|
|
