|
JMAX TUBING SET JIFP2000 IRRIGATION PUMP
|
Facility
|
OP
|
$163.00
|
|
| Hospital Charge Code |
4479291
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$55.42 |
| Max. Negotiated Rate |
$131.22 |
| Rate for Payer: Aetna of NY Commercial |
$114.10
|
| Rate for Payer: Aetna of NY Medicare |
$74.98
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$122.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$122.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$60.31
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$81.50
|
| Rate for Payer: Cash Price |
$122.25
|
| Rate for Payer: CDPHP Commercial |
$131.22
|
| Rate for Payer: CDPHP Medicare |
$60.31
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$130.40
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$130.40
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$130.40
|
| Rate for Payer: EmblemHealth Medicaid |
$130.40
|
| Rate for Payer: EmblemHealth Medicare |
$55.42
|
| Rate for Payer: EmblemHealth Select Care |
$117.36
|
| Rate for Payer: Fidelis Medicare |
$62.12
|
| Rate for Payer: Galaxy Health Commercial |
$105.95
|
| Rate for Payer: Hamaspik Choice Medicare |
$60.31
|
| Rate for Payer: Humana Medicare |
$60.31
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$114.10
|
| Rate for Payer: Local 1199SEIU Medicare |
$74.98
|
| Rate for Payer: MVP Health Care of NY Commercial |
$122.25
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$91.77
|
| Rate for Payer: MVP Health Care of NY Medicare |
$63.33
|
| Rate for Payer: United Healthcare Medicare |
$60.31
|
| Rate for Payer: WellCare Medicare |
$89.65
|
|
|
JMAX VERTICAL ISOLATION DRAPE D122822
|
Facility
|
IP
|
$163.00
|
|
| Hospital Charge Code |
4479290
|
|
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
|
|
|
JMAX VERTICAL ISOLATION DRAPE D122822
|
Facility
|
OP
|
$163.00
|
|
| Hospital Charge Code |
4479290
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$55.42 |
| Max. Negotiated Rate |
$131.22 |
| Rate for Payer: Aetna of NY Commercial |
$114.10
|
| Rate for Payer: Aetna of NY Medicare |
$74.98
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$122.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$122.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$60.31
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$81.50
|
| Rate for Payer: Cash Price |
$122.25
|
| Rate for Payer: CDPHP Commercial |
$131.22
|
| Rate for Payer: CDPHP Medicare |
$60.31
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$130.40
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$130.40
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$130.40
|
| Rate for Payer: EmblemHealth Medicaid |
$130.40
|
| Rate for Payer: EmblemHealth Medicare |
$55.42
|
| Rate for Payer: EmblemHealth Select Care |
$117.36
|
| Rate for Payer: Fidelis Medicare |
$62.12
|
| Rate for Payer: Galaxy Health Commercial |
$105.95
|
| Rate for Payer: Hamaspik Choice Medicare |
$60.31
|
| Rate for Payer: Humana Medicare |
$60.31
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$114.10
|
| Rate for Payer: Local 1199SEIU Medicare |
$74.98
|
| Rate for Payer: MVP Health Care of NY Commercial |
$122.25
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$91.77
|
| Rate for Payer: MVP Health Care of NY Medicare |
$63.33
|
| Rate for Payer: United Healthcare Medicare |
$60.31
|
| Rate for Payer: WellCare Medicare |
$89.65
|
|
|
JT EXCISION PROX END PHALA
|
Facility
|
IP
|
$9,262.00
|
|
|
Service Code
|
HCPCS 28160
|
| Hospital Charge Code |
4853011
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$6,020.30 |
| Max. Negotiated Rate |
$6,020.30 |
| Rate for Payer: Cash Price |
$6,946.50
|
| Rate for Payer: Galaxy Health Commercial |
$6,020.30
|
|
|
JT EXCISION PROX END PHALA
|
Facility
|
OP
|
$9,262.00
|
|
|
Service Code
|
HCPCS 28160
|
| Hospital Charge Code |
4853011
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$2,017.33 |
| Max. Negotiated Rate |
$7,455.91 |
| Rate for Payer: Aetna of NY Commercial |
$6,483.40
|
| Rate for Payer: Aetna of NY Medicare |
$4,260.52
|
| 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 |
$3,426.94
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$4,631.00
|
| Rate for Payer: Cash Price |
$6,946.50
|
| Rate for Payer: Cash Price |
$6,946.50
|
| Rate for Payer: Cash Price |
$6,946.50
|
| Rate for Payer: CDPHP Commercial |
$7,455.91
|
| Rate for Payer: CDPHP Medicare |
$3,426.94
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$7,409.60
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$7,409.60
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$7,409.60
|
| Rate for Payer: EmblemHealth Medicaid |
$7,409.60
|
| Rate for Payer: EmblemHealth Medicare |
$3,149.08
|
| Rate for Payer: EmblemHealth Select Care |
$6,668.64
|
| Rate for Payer: Fidelis Medicare |
$3,529.75
|
| Rate for Payer: Galaxy Health Commercial |
$6,020.30
|
| Rate for Payer: Hamaspik Choice Medicare |
$3,426.94
|
| Rate for Payer: Humana Medicare |
$3,426.94
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$6,483.40
|
| Rate for Payer: Local 1199SEIU Medicare |
$4,260.52
|
| Rate for Payer: MVP Health Care of NY Commercial |
$6,946.50
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$5,214.51
|
| Rate for Payer: MVP Health Care of NY Medicare |
$3,598.29
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$3,084.03
|
| Rate for Payer: United Healthcare Medicare |
$3,426.94
|
| Rate for Payer: WellCare Medicare |
$5,094.10
|
|
|
JUGULAR VENA CAVA FILTER
|
Facility
|
OP
|
$5,540.00
|
|
| Hospital Charge Code |
4471878
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$1,883.60 |
| Max. Negotiated Rate |
$4,459.70 |
| Rate for Payer: Aetna of NY Commercial |
$3,878.00
|
| Rate for Payer: Aetna of NY Medicare |
$2,548.40
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$4,155.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$4,155.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$2,049.80
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$2,770.00
|
| Rate for Payer: Cash Price |
$4,155.00
|
| Rate for Payer: CDPHP Commercial |
$4,459.70
|
| Rate for Payer: CDPHP Medicare |
$2,049.80
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$4,432.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$4,432.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$4,432.00
|
| Rate for Payer: EmblemHealth Medicaid |
$4,432.00
|
| Rate for Payer: EmblemHealth Medicare |
$1,883.60
|
| Rate for Payer: EmblemHealth Select Care |
$3,988.80
|
| Rate for Payer: Fidelis Medicare |
$2,111.29
|
| Rate for Payer: Galaxy Health Commercial |
$3,601.00
|
| Rate for Payer: Hamaspik Choice Medicare |
$2,049.80
|
| Rate for Payer: Humana Medicare |
$2,049.80
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$3,878.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$2,548.40
|
| Rate for Payer: MVP Health Care of NY Commercial |
$4,155.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$3,119.02
|
| Rate for Payer: MVP Health Care of NY Medicare |
$2,152.29
|
| Rate for Payer: United Healthcare Medicare |
$2,049.80
|
| Rate for Payer: WellCare Medicare |
$3,047.00
|
|
|
JUGULAR VENA CAVA FILTER
|
Facility
|
IP
|
$5,540.00
|
|
| Hospital Charge Code |
4471878
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$3,601.00 |
| Max. Negotiated Rate |
$3,601.00 |
| Rate for Payer: Cash Price |
$4,155.00
|
| Rate for Payer: Galaxy Health Commercial |
$3,601.00
|
|
|
KCENTRA, PER I.U. OF FACTOR IX ACTIVITY
|
Facility
|
IP
|
$7.50
|
|
|
Service Code
|
HCPCS J7168
|
| Hospital Charge Code |
4409216
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.38 |
| Max. Negotiated Rate |
$4.88 |
| Rate for Payer: Aetna of NY Commercial |
$4.12
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$3.38
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$3.38
|
| Rate for Payer: Cash Price |
$5.63
|
| Rate for Payer: Galaxy Health Commercial |
$4.88
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$4.12
|
| Rate for Payer: WellCare Medicare |
$4.12
|
|
|
KCENTRA, PER I.U. OF FACTOR IX ACTIVITY
|
Facility
|
OP
|
$7.50
|
|
|
Service Code
|
HCPCS J7168
|
| Hospital Charge Code |
4409216
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$6.04 |
| Rate for Payer: Aetna of NY Commercial |
$4.12
|
| Rate for Payer: Aetna of NY Medicare |
$3.45
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$3.38
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$3.38
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$2.78
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$3.75
|
| Rate for Payer: Cash Price |
$5.63
|
| Rate for Payer: Cash Price |
$5.63
|
| Rate for Payer: CDPHP Commercial |
$6.04
|
| Rate for Payer: CDPHP Medicare |
$2.78
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$6.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$6.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$6.00
|
| Rate for Payer: EmblemHealth Medicaid |
$6.00
|
| Rate for Payer: EmblemHealth Medicare |
$2.55
|
| Rate for Payer: EmblemHealth Select Care |
$5.40
|
| Rate for Payer: Fidelis Medicare |
$2.86
|
| Rate for Payer: Galaxy Health Commercial |
$4.88
|
| Rate for Payer: Hamaspik Choice Medicare |
$2.78
|
| Rate for Payer: Humana Medicare |
$2.78
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$4.12
|
| Rate for Payer: Local 1199SEIU Medicare |
$3.45
|
| Rate for Payer: MVP Health Care of NY Commercial |
$5.62
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$4.22
|
| Rate for Payer: MVP Health Care of NY Medicare |
$2.91
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$3.60
|
| Rate for Payer: United Healthcare Commercial |
$3.60
|
| Rate for Payer: United Healthcare Medicare |
$2.78
|
| Rate for Payer: WellCare Medicare |
$4.12
|
|
|
KEPPRA (LEVETIRACETAM)
|
Facility
|
IP
|
$75.00
|
|
|
Service Code
|
HCPCS 82542
|
| Hospital Charge Code |
4301187
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$48.75 |
| Max. Negotiated Rate |
$48.75 |
| Rate for Payer: Cash Price |
$56.25
|
| Rate for Payer: Galaxy Health Commercial |
$48.75
|
|
|
KEPPRA (LEVETIRACETAM)
|
Facility
|
OP
|
$75.00
|
|
|
Service Code
|
HCPCS 82542
|
| Hospital Charge Code |
4301187
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$24.09 |
| Max. Negotiated Rate |
$60.38 |
| Rate for Payer: Aetna of NY Commercial |
$48.75
|
| Rate for Payer: Aetna of NY Medicare |
$34.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$56.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$56.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$27.75
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$37.50
|
| Rate for Payer: Cash Price |
$56.25
|
| Rate for Payer: Cash Price |
$56.25
|
| Rate for Payer: CDPHP Commercial |
$60.38
|
| Rate for Payer: CDPHP Medicare |
$27.75
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$45.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$60.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$60.00
|
| Rate for Payer: EmblemHealth Medicaid |
$60.00
|
| Rate for Payer: EmblemHealth Medicare |
$25.50
|
| Rate for Payer: EmblemHealth Select Care |
$45.00
|
| Rate for Payer: Fidelis Medicare |
$28.58
|
| Rate for Payer: Galaxy Health Commercial |
$48.75
|
| Rate for Payer: Hamaspik Choice Medicare |
$27.75
|
| Rate for Payer: Humana Medicare |
$27.75
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$48.75
|
| Rate for Payer: Local 1199SEIU Medicare |
$34.50
|
| Rate for Payer: MVP Health Care of NY Commercial |
$56.25
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$42.22
|
| Rate for Payer: MVP Health Care of NY Medicare |
$29.14
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$56.25
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$24.09
|
| Rate for Payer: United Healthcare Commercial |
$56.25
|
| Rate for Payer: United Healthcare Medicare |
$27.75
|
| Rate for Payer: WellCare Medicare |
$41.25
|
|
|
KETAMINE 100 MG/ML INJECTION
|
Facility
|
OP
|
$6.18
|
|
|
Service Code
|
NDC 67457010810
|
| Hospital Charge Code |
4409206
|
|
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
|
|
|
KETAMINE 100 MG/ML INJECTION
|
Facility
|
IP
|
$6.18
|
|
|
Service Code
|
NDC 67457010810
|
| Hospital Charge Code |
4409206
|
|
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
|
|
|
KETAMINE HCL 50MG/ML SDV 10X10ML
|
Facility
|
IP
|
$22.15
|
|
|
Service Code
|
NDC 67457000110
|
| Hospital Charge Code |
4400400
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.18 |
| Max. Negotiated Rate |
$14.40 |
| Rate for Payer: Cash Price |
$16.61
|
| Rate for Payer: Galaxy Health Commercial |
$14.40
|
| Rate for Payer: WellCare Medicare |
$12.18
|
|
|
KETAMINE HCL 50MG/ML SDV 10X10ML
|
Facility
|
OP
|
$22.15
|
|
|
Service Code
|
NDC 67457000110
|
| Hospital Charge Code |
4400400
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.53 |
| Max. Negotiated Rate |
$17.83 |
| Rate for Payer: Aetna of NY Commercial |
$15.50
|
| Rate for Payer: Aetna of NY Medicare |
$10.19
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$16.61
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$16.61
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$8.20
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$11.08
|
| Rate for Payer: Cash Price |
$16.61
|
| Rate for Payer: CDPHP Commercial |
$17.83
|
| Rate for Payer: CDPHP Medicare |
$8.20
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$17.72
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$17.72
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$17.72
|
| Rate for Payer: EmblemHealth Medicaid |
$17.72
|
| Rate for Payer: EmblemHealth Medicare |
$7.53
|
| Rate for Payer: EmblemHealth Select Care |
$15.95
|
| Rate for Payer: Fidelis Medicare |
$8.44
|
| Rate for Payer: Galaxy Health Commercial |
$14.40
|
| Rate for Payer: Hamaspik Choice Medicare |
$8.20
|
| Rate for Payer: Humana Medicare |
$8.20
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$15.50
|
| Rate for Payer: Local 1199SEIU Medicare |
$10.19
|
| Rate for Payer: MVP Health Care of NY Commercial |
$16.61
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$12.47
|
| Rate for Payer: MVP Health Care of NY Medicare |
$8.61
|
| Rate for Payer: United Healthcare Medicare |
$8.20
|
| Rate for Payer: WellCare Medicare |
$12.18
|
|
|
KETAMINE INJECTION 10 MG/ML
|
Facility
|
IP
|
$54.85
|
|
|
Service Code
|
NDC 67457018120
|
| Hospital Charge Code |
4409172
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$30.17 |
| Max. Negotiated Rate |
$35.65 |
| Rate for Payer: Cash Price |
$41.14
|
| Rate for Payer: Galaxy Health Commercial |
$35.65
|
| Rate for Payer: WellCare Medicare |
$30.17
|
|
|
KETAMINE INJECTION 10 MG/ML
|
Facility
|
OP
|
$54.85
|
|
|
Service Code
|
NDC 67457018120
|
| Hospital Charge Code |
4409172
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.65 |
| Max. Negotiated Rate |
$44.15 |
| Rate for Payer: Aetna of NY Commercial |
$38.40
|
| Rate for Payer: Aetna of NY Medicare |
$25.23
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$41.14
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$41.14
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$20.29
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$27.42
|
| Rate for Payer: Cash Price |
$41.14
|
| Rate for Payer: CDPHP Commercial |
$44.15
|
| Rate for Payer: CDPHP Medicare |
$20.29
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$43.88
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$43.88
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$43.88
|
| Rate for Payer: EmblemHealth Medicaid |
$43.88
|
| Rate for Payer: EmblemHealth Medicare |
$18.65
|
| Rate for Payer: EmblemHealth Select Care |
$39.49
|
| Rate for Payer: Fidelis Medicare |
$20.90
|
| Rate for Payer: Galaxy Health Commercial |
$35.65
|
| Rate for Payer: Hamaspik Choice Medicare |
$20.29
|
| Rate for Payer: Humana Medicare |
$20.29
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$38.40
|
| Rate for Payer: Local 1199SEIU Medicare |
$25.23
|
| Rate for Payer: MVP Health Care of NY Commercial |
$41.14
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$30.88
|
| Rate for Payer: MVP Health Care of NY Medicare |
$21.31
|
| Rate for Payer: United Healthcare Medicare |
$20.29
|
| Rate for Payer: WellCare Medicare |
$30.17
|
|
|
KETOCONAZOLE 0.02 CRM 30 GM
|
Facility
|
OP
|
$625.32
|
|
|
Service Code
|
NDC 51672129802
|
| Hospital Charge Code |
4400401
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$212.61 |
| Max. Negotiated Rate |
$503.38 |
| Rate for Payer: Aetna of NY Commercial |
$437.72
|
| Rate for Payer: Aetna of NY Medicare |
$287.65
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$468.99
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$468.99
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$231.37
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$312.66
|
| Rate for Payer: Cash Price |
$468.99
|
| Rate for Payer: CDPHP Commercial |
$503.38
|
| Rate for Payer: CDPHP Medicare |
$231.37
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$500.26
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$500.26
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$500.26
|
| Rate for Payer: EmblemHealth Medicaid |
$500.26
|
| Rate for Payer: EmblemHealth Medicare |
$212.61
|
| Rate for Payer: EmblemHealth Select Care |
$450.23
|
| Rate for Payer: Fidelis Medicare |
$238.31
|
| Rate for Payer: Galaxy Health Commercial |
$406.46
|
| Rate for Payer: Hamaspik Choice Medicare |
$231.37
|
| Rate for Payer: Humana Medicare |
$231.37
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$437.72
|
| Rate for Payer: Local 1199SEIU Medicare |
$287.65
|
| Rate for Payer: MVP Health Care of NY Commercial |
$468.99
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$352.06
|
| Rate for Payer: MVP Health Care of NY Medicare |
$242.94
|
| Rate for Payer: United Healthcare Medicare |
$231.37
|
| Rate for Payer: WellCare Medicare |
$343.93
|
|
|
KETOCONAZOLE 0.02 CRM 30 GM
|
Facility
|
IP
|
$625.32
|
|
|
Service Code
|
NDC 51672129802
|
| Hospital Charge Code |
4400401
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$343.93 |
| Max. Negotiated Rate |
$406.46 |
| Rate for Payer: Cash Price |
$468.99
|
| Rate for Payer: Galaxy Health Commercial |
$406.46
|
| Rate for Payer: WellCare Medicare |
$343.93
|
|
|
ketorolac 0.5% OPHTH SOLUTION 1 ea, 5 mL
|
Facility
|
OP
|
$320.61
|
|
|
Service Code
|
NDC 60505100301
|
| Hospital Charge Code |
4401424
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$109.01 |
| Max. Negotiated Rate |
$258.09 |
| Rate for Payer: Aetna of NY Commercial |
$224.43
|
| Rate for Payer: Aetna of NY Medicare |
$147.48
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$240.46
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$240.46
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$118.63
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$160.30
|
| Rate for Payer: Cash Price |
$240.46
|
| Rate for Payer: CDPHP Commercial |
$258.09
|
| Rate for Payer: CDPHP Medicare |
$118.63
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$256.49
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$256.49
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$256.49
|
| Rate for Payer: EmblemHealth Medicaid |
$256.49
|
| Rate for Payer: EmblemHealth Medicare |
$109.01
|
| Rate for Payer: EmblemHealth Select Care |
$230.84
|
| Rate for Payer: Fidelis Medicare |
$122.18
|
| Rate for Payer: Galaxy Health Commercial |
$208.40
|
| Rate for Payer: Hamaspik Choice Medicare |
$118.63
|
| Rate for Payer: Humana Medicare |
$118.63
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$224.43
|
| Rate for Payer: Local 1199SEIU Medicare |
$147.48
|
| Rate for Payer: MVP Health Care of NY Commercial |
$240.46
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$180.50
|
| Rate for Payer: MVP Health Care of NY Medicare |
$124.56
|
| Rate for Payer: United Healthcare Medicare |
$118.63
|
| Rate for Payer: WellCare Medicare |
$176.34
|
|
|
ketorolac 0.5% OPHTH SOLUTION 1 ea, 5 mL
|
Facility
|
IP
|
$320.61
|
|
|
Service Code
|
NDC 60505100301
|
| Hospital Charge Code |
4401424
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$176.34 |
| Max. Negotiated Rate |
$208.40 |
| Rate for Payer: Cash Price |
$240.46
|
| Rate for Payer: Galaxy Health Commercial |
$208.40
|
| Rate for Payer: WellCare Medicare |
$176.34
|
|
|
KETOROLAC TAB 10 MG
|
Facility
|
IP
|
$6.70
|
|
|
Service Code
|
NDC 00093031401
|
| Hospital Charge Code |
4409043
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.68 |
| Max. Negotiated Rate |
$4.36 |
| Rate for Payer: Cash Price |
$5.03
|
| Rate for Payer: Galaxy Health Commercial |
$4.36
|
| Rate for Payer: WellCare Medicare |
$3.68
|
|
|
KETOROLAC TAB 10 MG
|
Facility
|
OP
|
$6.70
|
|
|
Service Code
|
NDC 00093031401
|
| Hospital Charge Code |
4409043
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.28 |
| Max. Negotiated Rate |
$5.39 |
| Rate for Payer: Aetna of NY Commercial |
$4.69
|
| Rate for Payer: Aetna of NY Medicare |
$3.08
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$5.02
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$5.02
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$2.48
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$3.35
|
| Rate for Payer: Cash Price |
$5.03
|
| Rate for Payer: CDPHP Commercial |
$5.39
|
| Rate for Payer: CDPHP Medicare |
$2.48
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$5.36
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$5.36
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$5.36
|
| Rate for Payer: EmblemHealth Medicaid |
$5.36
|
| Rate for Payer: EmblemHealth Medicare |
$2.28
|
| Rate for Payer: EmblemHealth Select Care |
$4.82
|
| Rate for Payer: Fidelis Medicare |
$2.55
|
| Rate for Payer: Galaxy Health Commercial |
$4.36
|
| Rate for Payer: Hamaspik Choice Medicare |
$2.48
|
| Rate for Payer: Humana Medicare |
$2.48
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$4.69
|
| Rate for Payer: Local 1199SEIU Medicare |
$3.08
|
| Rate for Payer: MVP Health Care of NY Commercial |
$5.02
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$3.77
|
| Rate for Payer: MVP Health Care of NY Medicare |
$2.60
|
| Rate for Payer: United Healthcare Medicare |
$2.48
|
| Rate for Payer: WellCare Medicare |
$3.68
|
|
|
KETOROLAC TROMETHAMINE 0.004 DROP 5 ML
|
Facility
|
IP
|
$351.00
|
|
| Hospital Charge Code |
4400404
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$193.05 |
| Max. Negotiated Rate |
$228.15 |
| Rate for Payer: Cash Price |
$263.25
|
| Rate for Payer: Galaxy Health Commercial |
$228.15
|
| Rate for Payer: WellCare Medicare |
$193.05
|
|
|
KETOROLAC TROMETHAMINE 0.004 DROP 5 ML
|
Facility
|
OP
|
$351.00
|
|
| Hospital Charge Code |
4400404
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$119.34 |
| Max. Negotiated Rate |
$282.56 |
| Rate for Payer: Aetna of NY Commercial |
$245.70
|
| Rate for Payer: Aetna of NY Medicare |
$161.46
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$263.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$263.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$129.87
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$175.50
|
| Rate for Payer: Cash Price |
$263.25
|
| Rate for Payer: CDPHP Commercial |
$282.56
|
| Rate for Payer: CDPHP Medicare |
$129.87
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$280.80
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$280.80
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$280.80
|
| Rate for Payer: EmblemHealth Medicaid |
$280.80
|
| Rate for Payer: EmblemHealth Medicare |
$119.34
|
| Rate for Payer: EmblemHealth Select Care |
$252.72
|
| Rate for Payer: Fidelis Medicare |
$133.77
|
| Rate for Payer: Galaxy Health Commercial |
$228.15
|
| Rate for Payer: Hamaspik Choice Medicare |
$129.87
|
| Rate for Payer: Humana Medicare |
$129.87
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$245.70
|
| Rate for Payer: Local 1199SEIU Medicare |
$161.46
|
| Rate for Payer: MVP Health Care of NY Commercial |
$263.25
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$197.61
|
| Rate for Payer: MVP Health Care of NY Medicare |
$136.36
|
| Rate for Payer: United Healthcare Medicare |
$129.87
|
| Rate for Payer: WellCare Medicare |
$193.05
|
|
