|
Jantoven 2 MG TABLET 2 mg, 100 eaches
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
NDC 00832121201
|
| Hospital Charge Code |
4401430
|
|
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
|
|
|
Jantoven 2 MG TABLET 2 mg, 100 eaches
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
NDC 00832121201
|
| Hospital Charge Code |
4401430
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.04 |
| Max. Negotiated Rate |
$4.83 |
| Rate for Payer: Aetna of NY Commercial |
$4.20
|
| Rate for Payer: Aetna of NY Medicare |
$2.76
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$4.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$4.50
|
| 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: CDPHP Commercial |
$4.83
|
| Rate for Payer: CDPHP Medicare |
$2.22
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$4.80
|
| 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 |
$4.32
|
| 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 |
$4.20
|
| 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: United Healthcare Medicare |
$2.22
|
| Rate for Payer: WellCare Medicare |
$3.30
|
|
|
Jantoven 3 MG TABLET 1 ea, 1 each
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
NDC 00832121489
|
| Hospital Charge Code |
4401421
|
|
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
|
|
|
Jantoven 3 MG TABLET 1 ea, 1 each
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
NDC 00832121489
|
| Hospital Charge Code |
4401421
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.04 |
| Max. Negotiated Rate |
$4.83 |
| Rate for Payer: Aetna of NY Commercial |
$4.20
|
| Rate for Payer: Aetna of NY Medicare |
$2.76
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$4.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$4.50
|
| 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: CDPHP Commercial |
$4.83
|
| Rate for Payer: CDPHP Medicare |
$2.22
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$4.80
|
| 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 |
$4.32
|
| 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 |
$4.20
|
| 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: United Healthcare Medicare |
$2.22
|
| Rate for Payer: WellCare Medicare |
$3.30
|
|
|
Jantoven 4MG TABS 100 EA
|
Facility
|
IP
|
$7.47
|
|
|
Service Code
|
NDC 00056016875
|
| Hospital Charge Code |
4400192
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.11 |
| Max. Negotiated Rate |
$4.86 |
| Rate for Payer: Cash Price |
$5.60
|
| Rate for Payer: Galaxy Health Commercial |
$4.86
|
| Rate for Payer: WellCare Medicare |
$4.11
|
|
|
Jantoven 4MG TABS 100 EA
|
Facility
|
OP
|
$7.47
|
|
|
Service Code
|
NDC 00056016875
|
| Hospital Charge Code |
4400192
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.54 |
| Max. Negotiated Rate |
$6.01 |
| Rate for Payer: Aetna of NY Commercial |
$5.23
|
| Rate for Payer: Aetna of NY Medicare |
$3.44
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$5.60
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$5.60
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$2.76
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$3.74
|
| Rate for Payer: Cash Price |
$5.60
|
| Rate for Payer: CDPHP Commercial |
$6.01
|
| Rate for Payer: CDPHP Medicare |
$2.76
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$5.98
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$5.98
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$5.98
|
| Rate for Payer: EmblemHealth Medicaid |
$5.98
|
| Rate for Payer: EmblemHealth Medicare |
$2.54
|
| Rate for Payer: EmblemHealth Select Care |
$5.38
|
| Rate for Payer: Fidelis Medicare |
$2.85
|
| Rate for Payer: Galaxy Health Commercial |
$4.86
|
| Rate for Payer: Hamaspik Choice Medicare |
$2.76
|
| Rate for Payer: Humana Medicare |
$2.76
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$5.23
|
| Rate for Payer: Local 1199SEIU Medicare |
$3.44
|
| Rate for Payer: MVP Health Care of NY Commercial |
$5.60
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$4.21
|
| Rate for Payer: MVP Health Care of NY Medicare |
$2.90
|
| Rate for Payer: United Healthcare Medicare |
$2.76
|
| Rate for Payer: WellCare Medicare |
$4.11
|
|
|
Jantoven 5 MG TABLET 5 mg, 100 eaches
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
NDC 00832121601
|
| Hospital Charge Code |
4401470
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.04 |
| Max. Negotiated Rate |
$4.83 |
| Rate for Payer: Aetna of NY Commercial |
$4.20
|
| Rate for Payer: Aetna of NY Medicare |
$2.76
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$4.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$4.50
|
| 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: CDPHP Commercial |
$4.83
|
| Rate for Payer: CDPHP Medicare |
$2.22
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$4.80
|
| 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 |
$4.32
|
| 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 |
$4.20
|
| 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: United Healthcare Medicare |
$2.22
|
| Rate for Payer: WellCare Medicare |
$3.30
|
|
|
Jantoven 5 MG TABLET 5 mg, 100 eaches
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
NDC 00832121601
|
| Hospital Charge Code |
4401470
|
|
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
|
|
|
Januvia 100 MG TABLET 100 mg, 1 each
|
Facility
|
IP
|
$68.77
|
|
|
Service Code
|
NDC 00006027701
|
| Hospital Charge Code |
4401573
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.82 |
| Max. Negotiated Rate |
$44.70 |
| Rate for Payer: Cash Price |
$51.58
|
| Rate for Payer: Galaxy Health Commercial |
$44.70
|
| Rate for Payer: WellCare Medicare |
$37.82
|
|
|
Januvia 100 MG TABLET 100 mg, 1 each
|
Facility
|
OP
|
$68.77
|
|
|
Service Code
|
NDC 00006027701
|
| Hospital Charge Code |
4401573
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.38 |
| Max. Negotiated Rate |
$55.36 |
| Rate for Payer: Aetna of NY Commercial |
$48.14
|
| Rate for Payer: Aetna of NY Medicare |
$31.63
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$51.58
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$51.58
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$25.44
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$34.38
|
| Rate for Payer: Cash Price |
$51.58
|
| Rate for Payer: CDPHP Commercial |
$55.36
|
| Rate for Payer: CDPHP Medicare |
$25.44
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$55.02
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$55.02
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$55.02
|
| Rate for Payer: EmblemHealth Medicaid |
$55.02
|
| Rate for Payer: EmblemHealth Medicare |
$23.38
|
| Rate for Payer: EmblemHealth Select Care |
$49.51
|
| Rate for Payer: Fidelis Medicare |
$26.21
|
| Rate for Payer: Galaxy Health Commercial |
$44.70
|
| Rate for Payer: Hamaspik Choice Medicare |
$25.44
|
| Rate for Payer: Humana Medicare |
$25.44
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$48.14
|
| Rate for Payer: Local 1199SEIU Medicare |
$31.63
|
| Rate for Payer: MVP Health Care of NY Commercial |
$51.58
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$38.72
|
| Rate for Payer: MVP Health Care of NY Medicare |
$26.72
|
| Rate for Payer: United Healthcare Medicare |
$25.44
|
| Rate for Payer: WellCare Medicare |
$37.82
|
|
|
JANUVIA 25 MG
|
Facility
|
IP
|
$44.81
|
|
|
Service Code
|
NDC 00006022128
|
| Hospital Charge Code |
4401250
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.65 |
| Max. Negotiated Rate |
$29.13 |
| Rate for Payer: Cash Price |
$33.61
|
| Rate for Payer: Galaxy Health Commercial |
$29.13
|
| Rate for Payer: WellCare Medicare |
$24.65
|
|
|
JANUVIA 25 MG
|
Facility
|
OP
|
$44.81
|
|
|
Service Code
|
NDC 00006022128
|
| Hospital Charge Code |
4401250
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.24 |
| Max. Negotiated Rate |
$36.07 |
| Rate for Payer: Aetna of NY Commercial |
$31.37
|
| Rate for Payer: Aetna of NY Medicare |
$20.61
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$33.61
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$33.61
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$16.58
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$22.40
|
| Rate for Payer: Cash Price |
$33.61
|
| Rate for Payer: CDPHP Commercial |
$36.07
|
| Rate for Payer: CDPHP Medicare |
$16.58
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$35.85
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$35.85
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$35.85
|
| Rate for Payer: EmblemHealth Medicaid |
$35.85
|
| Rate for Payer: EmblemHealth Medicare |
$15.24
|
| Rate for Payer: EmblemHealth Select Care |
$32.26
|
| Rate for Payer: Fidelis Medicare |
$17.08
|
| Rate for Payer: Galaxy Health Commercial |
$29.13
|
| Rate for Payer: Hamaspik Choice Medicare |
$16.58
|
| Rate for Payer: Humana Medicare |
$16.58
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$31.37
|
| Rate for Payer: Local 1199SEIU Medicare |
$20.61
|
| Rate for Payer: MVP Health Care of NY Commercial |
$33.61
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$25.23
|
| Rate for Payer: MVP Health Care of NY Medicare |
$17.41
|
| Rate for Payer: United Healthcare Medicare |
$16.58
|
| Rate for Payer: WellCare Medicare |
$24.65
|
|
|
JARDIANCE 10 MG TABLET 1 ea, 30 eaches
|
Facility
|
IP
|
$63.00
|
|
|
Service Code
|
NDC 00597015230
|
| Hospital Charge Code |
4401415
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$34.65 |
| Max. Negotiated Rate |
$40.95 |
| Rate for Payer: Cash Price |
$47.25
|
| Rate for Payer: Galaxy Health Commercial |
$40.95
|
| Rate for Payer: WellCare Medicare |
$34.65
|
|
|
JARDIANCE 10 MG TABLET 1 ea, 30 eaches
|
Facility
|
OP
|
$63.00
|
|
|
Service Code
|
NDC 00597015230
|
| Hospital Charge Code |
4401415
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.42 |
| Max. Negotiated Rate |
$50.72 |
| Rate for Payer: Aetna of NY Commercial |
$44.10
|
| Rate for Payer: Aetna of NY Medicare |
$28.98
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$47.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$47.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$23.31
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$31.50
|
| Rate for Payer: Cash Price |
$47.25
|
| Rate for Payer: CDPHP Commercial |
$50.72
|
| Rate for Payer: CDPHP Medicare |
$23.31
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$50.40
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$50.40
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$50.40
|
| Rate for Payer: EmblemHealth Medicaid |
$50.40
|
| Rate for Payer: EmblemHealth Medicare |
$21.42
|
| Rate for Payer: EmblemHealth Select Care |
$45.36
|
| Rate for Payer: Fidelis Medicare |
$24.01
|
| Rate for Payer: Galaxy Health Commercial |
$40.95
|
| Rate for Payer: Hamaspik Choice Medicare |
$23.31
|
| Rate for Payer: Humana Medicare |
$23.31
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$44.10
|
| Rate for Payer: Local 1199SEIU Medicare |
$28.98
|
| Rate for Payer: MVP Health Care of NY Commercial |
$47.25
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$35.47
|
| Rate for Payer: MVP Health Care of NY Medicare |
$24.48
|
| Rate for Payer: United Healthcare Medicare |
$23.31
|
| Rate for Payer: WellCare Medicare |
$34.65
|
|
|
JARDIANCE 25 MG TABLET 1 ea, 30 eaches
|
Facility
|
OP
|
$63.00
|
|
|
Service Code
|
NDC 00597015330
|
| Hospital Charge Code |
4401416
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.42 |
| Max. Negotiated Rate |
$50.72 |
| Rate for Payer: Aetna of NY Commercial |
$44.10
|
| Rate for Payer: Aetna of NY Medicare |
$28.98
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$47.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$47.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$23.31
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$31.50
|
| Rate for Payer: Cash Price |
$47.25
|
| Rate for Payer: CDPHP Commercial |
$50.72
|
| Rate for Payer: CDPHP Medicare |
$23.31
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$50.40
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$50.40
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$50.40
|
| Rate for Payer: EmblemHealth Medicaid |
$50.40
|
| Rate for Payer: EmblemHealth Medicare |
$21.42
|
| Rate for Payer: EmblemHealth Select Care |
$45.36
|
| Rate for Payer: Fidelis Medicare |
$24.01
|
| Rate for Payer: Galaxy Health Commercial |
$40.95
|
| Rate for Payer: Hamaspik Choice Medicare |
$23.31
|
| Rate for Payer: Humana Medicare |
$23.31
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$44.10
|
| Rate for Payer: Local 1199SEIU Medicare |
$28.98
|
| Rate for Payer: MVP Health Care of NY Commercial |
$47.25
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$35.47
|
| Rate for Payer: MVP Health Care of NY Medicare |
$24.48
|
| Rate for Payer: United Healthcare Medicare |
$23.31
|
| Rate for Payer: WellCare Medicare |
$34.65
|
|
|
JARDIANCE 25 MG TABLET 1 ea, 30 eaches
|
Facility
|
IP
|
$63.00
|
|
|
Service Code
|
NDC 00597015330
|
| Hospital Charge Code |
4401416
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$34.65 |
| Max. Negotiated Rate |
$40.95 |
| Rate for Payer: Cash Price |
$47.25
|
| Rate for Payer: Galaxy Health Commercial |
$40.95
|
| Rate for Payer: WellCare Medicare |
$34.65
|
|
|
JEVITY 1.5 CAL LIQUID 1.5 mL, 237 mL
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
NDC 70074064628
|
| Hospital Charge Code |
4401526
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.04 |
| Max. Negotiated Rate |
$4.83 |
| Rate for Payer: Aetna of NY Commercial |
$4.20
|
| Rate for Payer: Aetna of NY Medicare |
$2.76
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$4.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$4.50
|
| 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: CDPHP Commercial |
$4.83
|
| Rate for Payer: CDPHP Medicare |
$2.22
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$4.80
|
| 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 |
$4.32
|
| 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 |
$4.20
|
| 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: United Healthcare Medicare |
$2.22
|
| Rate for Payer: WellCare Medicare |
$3.30
|
|
|
JEVITY 1.5 CAL LIQUID 1.5 mL, 237 mL
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
NDC 70074064628
|
| Hospital Charge Code |
4401526
|
|
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
|
|
|
JMAX DISP ACCESS KIT W/3 REAMERS FINE 98
|
Facility
|
OP
|
$4,456.00
|
|
| Hospital Charge Code |
4479292
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$1,515.04 |
| Max. Negotiated Rate |
$3,587.08 |
| Rate for Payer: Aetna of NY Commercial |
$3,119.20
|
| Rate for Payer: Aetna of NY Medicare |
$2,049.76
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$3,342.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$3,342.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$1,648.72
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$2,228.00
|
| Rate for Payer: Cash Price |
$3,342.00
|
| Rate for Payer: CDPHP Commercial |
$3,587.08
|
| Rate for Payer: CDPHP Medicare |
$1,648.72
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$3,564.80
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$3,564.80
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$3,564.80
|
| Rate for Payer: EmblemHealth Medicaid |
$3,564.80
|
| Rate for Payer: EmblemHealth Medicare |
$1,515.04
|
| Rate for Payer: EmblemHealth Select Care |
$3,208.32
|
| Rate for Payer: Fidelis Medicare |
$1,698.18
|
| Rate for Payer: Galaxy Health Commercial |
$2,896.40
|
| Rate for Payer: Hamaspik Choice Medicare |
$1,648.72
|
| Rate for Payer: Humana Medicare |
$1,648.72
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$3,119.20
|
| Rate for Payer: Local 1199SEIU Medicare |
$2,049.76
|
| Rate for Payer: MVP Health Care of NY Commercial |
$3,342.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$2,508.73
|
| Rate for Payer: MVP Health Care of NY Medicare |
$1,731.16
|
| Rate for Payer: United Healthcare Medicare |
$1,648.72
|
| Rate for Payer: WellCare Medicare |
$2,450.80
|
|
|
JMAX DISP ACCESS KIT W/3 REAMERS FINE 98
|
Facility
|
IP
|
$4,456.00
|
|
| Hospital Charge Code |
4479292
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$2,896.40 |
| Max. Negotiated Rate |
$2,896.40 |
| Rate for Payer: Cash Price |
$3,342.00
|
| Rate for Payer: Galaxy Health Commercial |
$2,896.40
|
|
|
JMAX NEEDLE GUIDE WIRE SET
|
Facility
|
OP
|
$224.00
|
|
| Hospital Charge Code |
4479293
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$76.16 |
| Max. Negotiated Rate |
$180.32 |
| Rate for Payer: Aetna of NY Commercial |
$156.80
|
| Rate for Payer: Aetna of NY Medicare |
$103.04
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$168.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$168.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$82.88
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$112.00
|
| Rate for Payer: Cash Price |
$168.00
|
| Rate for Payer: CDPHP Commercial |
$180.32
|
| Rate for Payer: CDPHP Medicare |
$82.88
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$179.20
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$179.20
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$179.20
|
| Rate for Payer: EmblemHealth Medicaid |
$179.20
|
| Rate for Payer: EmblemHealth Medicare |
$76.16
|
| Rate for Payer: EmblemHealth Select Care |
$161.28
|
| Rate for Payer: Fidelis Medicare |
$85.37
|
| Rate for Payer: Galaxy Health Commercial |
$145.60
|
| Rate for Payer: Hamaspik Choice Medicare |
$82.88
|
| Rate for Payer: Humana Medicare |
$82.88
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$156.80
|
| Rate for Payer: Local 1199SEIU Medicare |
$103.04
|
| Rate for Payer: MVP Health Care of NY Commercial |
$168.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$126.11
|
| Rate for Payer: MVP Health Care of NY Medicare |
$87.02
|
| Rate for Payer: United Healthcare Medicare |
$82.88
|
| Rate for Payer: WellCare Medicare |
$123.20
|
|
|
JMAX NEEDLE GUIDE WIRE SET
|
Facility
|
IP
|
$224.00
|
|
| Hospital Charge Code |
4479293
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$145.60 |
| Max. Negotiated Rate |
$145.60 |
| Rate for Payer: Cash Price |
$168.00
|
| Rate for Payer: Galaxy Health Commercial |
$145.60
|
|
|
JMAX TRIGGER FLEX LOT 13070112A
|
Facility
|
IP
|
$1,296.00
|
|
| Hospital Charge Code |
4479289
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$842.40 |
| Max. Negotiated Rate |
$842.40 |
| Rate for Payer: Cash Price |
$972.00
|
| Rate for Payer: Galaxy Health Commercial |
$842.40
|
|
|
JMAX TRIGGER FLEX LOT 13070112A
|
Facility
|
OP
|
$1,296.00
|
|
| Hospital Charge Code |
4479289
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$440.64 |
| Max. Negotiated Rate |
$1,043.28 |
| Rate for Payer: Aetna of NY Commercial |
$907.20
|
| Rate for Payer: Aetna of NY Medicare |
$596.16
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$972.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$972.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$479.52
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$648.00
|
| Rate for Payer: Cash Price |
$972.00
|
| Rate for Payer: CDPHP Commercial |
$1,043.28
|
| Rate for Payer: CDPHP Medicare |
$479.52
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$1,036.80
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$1,036.80
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$1,036.80
|
| Rate for Payer: EmblemHealth Medicaid |
$1,036.80
|
| Rate for Payer: EmblemHealth Medicare |
$440.64
|
| Rate for Payer: EmblemHealth Select Care |
$933.12
|
| Rate for Payer: Fidelis Medicare |
$493.91
|
| Rate for Payer: Galaxy Health Commercial |
$842.40
|
| Rate for Payer: Hamaspik Choice Medicare |
$479.52
|
| Rate for Payer: Humana Medicare |
$479.52
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$907.20
|
| Rate for Payer: Local 1199SEIU Medicare |
$596.16
|
| Rate for Payer: MVP Health Care of NY Commercial |
$972.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$729.65
|
| Rate for Payer: MVP Health Care of NY Medicare |
$503.50
|
| Rate for Payer: United Healthcare Medicare |
$479.52
|
| Rate for Payer: WellCare Medicare |
$712.80
|
|
|
JMAX TUBING SET JIFP2000 IRRIGATION PUMP
|
Facility
|
IP
|
$163.00
|
|
| Hospital Charge Code |
4479291
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$105.95 |
| Max. Negotiated Rate |
$105.95 |
| Rate for Payer: Cash Price |
$122.25
|
| Rate for Payer: Galaxy Health Commercial |
$105.95
|
|
