|
levothyroxine 112 MCG TABLET 112 mcg, 90 eaches
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
NDC 00378181177
|
| Hospital Charge Code |
4401306
|
|
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
|
|
|
levothyroxine 125 MCG TABLET 125 mcg, 100 eaches
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
NDC 51079044320
|
| Hospital Charge Code |
4401298
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.10 |
| Max. Negotiated Rate |
$1.30 |
| Rate for Payer: Cash Price |
$1.50
|
| Rate for Payer: Galaxy Health Commercial |
$1.30
|
| Rate for Payer: WellCare Medicare |
$1.10
|
|
|
levothyroxine 125 MCG TABLET 125 mcg, 100 eaches
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
NDC 51079044320
|
| Hospital Charge Code |
4401298
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.68 |
| Max. Negotiated Rate |
$1.61 |
| Rate for Payer: Aetna of NY Commercial |
$1.40
|
| Rate for Payer: Aetna of NY Medicare |
$0.92
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$1.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$1.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$0.74
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$1.00
|
| Rate for Payer: Cash Price |
$1.50
|
| Rate for Payer: CDPHP Commercial |
$1.61
|
| Rate for Payer: CDPHP Medicare |
$0.74
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$1.60
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$1.60
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$1.60
|
| Rate for Payer: EmblemHealth Medicaid |
$1.60
|
| Rate for Payer: EmblemHealth Medicare |
$0.68
|
| Rate for Payer: EmblemHealth Select Care |
$1.44
|
| Rate for Payer: Fidelis Medicare |
$0.76
|
| Rate for Payer: Galaxy Health Commercial |
$1.30
|
| Rate for Payer: Hamaspik Choice Medicare |
$0.74
|
| Rate for Payer: Humana Medicare |
$0.74
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1.40
|
| Rate for Payer: Local 1199SEIU Medicare |
$0.92
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1.50
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$1.13
|
| Rate for Payer: MVP Health Care of NY Medicare |
$0.78
|
| Rate for Payer: United Healthcare Medicare |
$0.74
|
| Rate for Payer: WellCare Medicare |
$1.10
|
|
|
levothyroxine 137 MCG TABLET 137 mcg, 1 each
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
NDC 60687056311
|
| Hospital Charge Code |
4401454
|
|
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
|
|
|
levothyroxine 137 MCG TABLET 137 mcg, 1 each
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
NDC 60687056311
|
| Hospital Charge Code |
4401454
|
|
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
|
|
|
levothyroxine 50 MCG TABLET 50 mcg, 100 eaches
|
Facility
|
OP
|
$1.50
|
|
|
Service Code
|
NDC 51079044001
|
| Hospital Charge Code |
4401297
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$1.21 |
| Rate for Payer: Aetna of NY Commercial |
$1.05
|
| Rate for Payer: Aetna of NY Medicare |
$0.69
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$1.12
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$1.12
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$0.56
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$0.75
|
| Rate for Payer: Cash Price |
$1.13
|
| Rate for Payer: CDPHP Commercial |
$1.21
|
| Rate for Payer: CDPHP Medicare |
$0.56
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$1.20
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$1.20
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$1.20
|
| Rate for Payer: EmblemHealth Medicaid |
$1.20
|
| Rate for Payer: EmblemHealth Medicare |
$0.51
|
| Rate for Payer: EmblemHealth Select Care |
$1.08
|
| Rate for Payer: Fidelis Medicare |
$0.57
|
| Rate for Payer: Galaxy Health Commercial |
$0.98
|
| Rate for Payer: Hamaspik Choice Medicare |
$0.56
|
| Rate for Payer: Humana Medicare |
$0.56
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1.05
|
| Rate for Payer: Local 1199SEIU Medicare |
$0.69
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1.12
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$0.84
|
| Rate for Payer: MVP Health Care of NY Medicare |
$0.58
|
| Rate for Payer: United Healthcare Medicare |
$0.56
|
| Rate for Payer: WellCare Medicare |
$0.83
|
|
|
levothyroxine 50 MCG TABLET 50 mcg, 100 eaches
|
Facility
|
IP
|
$1.50
|
|
|
Service Code
|
NDC 51079044001
|
| Hospital Charge Code |
4401297
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.83 |
| Max. Negotiated Rate |
$0.98 |
| Rate for Payer: Cash Price |
$1.13
|
| Rate for Payer: Galaxy Health Commercial |
$0.98
|
| Rate for Payer: WellCare Medicare |
$0.83
|
|
|
LEVOTHYROXINE 75 MCG TABLET
|
Facility
|
IP
|
$1.50
|
|
|
Service Code
|
NDC 51079044120
|
| Hospital Charge Code |
4401285
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.83 |
| Max. Negotiated Rate |
$0.98 |
| Rate for Payer: Cash Price |
$1.13
|
| Rate for Payer: Galaxy Health Commercial |
$0.98
|
| Rate for Payer: WellCare Medicare |
$0.83
|
|
|
LEVOTHYROXINE 75 MCG TABLET
|
Facility
|
OP
|
$1.50
|
|
|
Service Code
|
NDC 51079044120
|
| Hospital Charge Code |
4401285
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$1.21 |
| Rate for Payer: Aetna of NY Commercial |
$1.05
|
| Rate for Payer: Aetna of NY Medicare |
$0.69
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$1.12
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$1.12
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$0.56
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$0.75
|
| Rate for Payer: Cash Price |
$1.13
|
| Rate for Payer: CDPHP Commercial |
$1.21
|
| Rate for Payer: CDPHP Medicare |
$0.56
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$1.20
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$1.20
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$1.20
|
| Rate for Payer: EmblemHealth Medicaid |
$1.20
|
| Rate for Payer: EmblemHealth Medicare |
$0.51
|
| Rate for Payer: EmblemHealth Select Care |
$1.08
|
| Rate for Payer: Fidelis Medicare |
$0.57
|
| Rate for Payer: Galaxy Health Commercial |
$0.98
|
| Rate for Payer: Hamaspik Choice Medicare |
$0.56
|
| Rate for Payer: Humana Medicare |
$0.56
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1.05
|
| Rate for Payer: Local 1199SEIU Medicare |
$0.69
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1.12
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$0.84
|
| Rate for Payer: MVP Health Care of NY Medicare |
$0.58
|
| Rate for Payer: United Healthcare Medicare |
$0.56
|
| Rate for Payer: WellCare Medicare |
$0.83
|
|
|
LEVOTHYROXINE 88 MCG TABLET
|
Facility
|
OP
|
$6.18
|
|
|
Service Code
|
NDC 42292003820
|
| Hospital Charge Code |
4401284
|
|
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
|
|
|
LEVOTHYROXINE 88 MCG TABLET
|
Facility
|
IP
|
$6.18
|
|
|
Service Code
|
NDC 42292003820
|
| Hospital Charge Code |
4401284
|
|
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
|
|
|
LEVOTHYROXINE SODIUM
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
NDC 00378180077
|
| Hospital Charge Code |
4401286
|
|
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
|
|
|
LEVOTHYROXINE SODIUM
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
NDC 00378180077
|
| Hospital Charge Code |
4401286
|
|
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
|
|
|
LEXISCAN .1MG
|
Facility
|
IP
|
$188.00
|
|
|
Service Code
|
HCPCS J2785
|
| Hospital Charge Code |
4211246
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.05 |
| Max. Negotiated Rate |
$122.20 |
| Rate for Payer: Aetna of NY Commercial |
$103.40
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$7.05
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$7.05
|
| Rate for Payer: Cash Price |
$141.00
|
| Rate for Payer: Cash Price |
$141.00
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$7.05
|
| Rate for Payer: EmblemHealth Select Care |
$7.05
|
| Rate for Payer: Galaxy Health Commercial |
$122.20
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$103.40
|
| Rate for Payer: WellCare Medicare |
$103.40
|
|
|
LEXISCAN .1MG
|
Facility
|
OP
|
$188.00
|
|
|
Service Code
|
HCPCS J2785
|
| Hospital Charge Code |
4211246
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.05 |
| Max. Negotiated Rate |
$151.34 |
| Rate for Payer: Aetna of NY Commercial |
$103.40
|
| Rate for Payer: Aetna of NY Medicare |
$86.48
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$7.05
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$7.05
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$69.56
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$94.00
|
| Rate for Payer: Cash Price |
$141.00
|
| Rate for Payer: Cash Price |
$141.00
|
| Rate for Payer: CDPHP Commercial |
$151.34
|
| Rate for Payer: CDPHP Medicare |
$69.56
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$7.05
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$150.40
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$150.40
|
| Rate for Payer: EmblemHealth Medicaid |
$150.40
|
| Rate for Payer: EmblemHealth Medicare |
$63.92
|
| Rate for Payer: EmblemHealth Select Care |
$7.05
|
| Rate for Payer: Fidelis Medicare |
$71.65
|
| Rate for Payer: Galaxy Health Commercial |
$122.20
|
| Rate for Payer: Hamaspik Choice Medicare |
$69.56
|
| Rate for Payer: Humana Medicare |
$69.56
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$103.40
|
| Rate for Payer: Local 1199SEIU Medicare |
$86.48
|
| Rate for Payer: MVP Health Care of NY Commercial |
$141.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$105.84
|
| Rate for Payer: MVP Health Care of NY Medicare |
$73.04
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$102.76
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$7.05
|
| Rate for Payer: United Healthcare Commercial |
$102.76
|
| Rate for Payer: United Healthcare Medicare |
$69.56
|
| Rate for Payer: WellCare Medicare |
$103.40
|
|
|
LIALDA DR 1.2 GM TABLET 1.2 g, 120 eaches
|
Facility
|
OP
|
$34.00
|
|
|
Service Code
|
NDC 54092047612
|
| Hospital Charge Code |
4401434
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.56 |
| Max. Negotiated Rate |
$27.37 |
| Rate for Payer: Aetna of NY Commercial |
$23.80
|
| Rate for Payer: Aetna of NY Medicare |
$15.64
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$25.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$25.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$12.58
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$17.00
|
| Rate for Payer: Cash Price |
$25.50
|
| Rate for Payer: CDPHP Commercial |
$27.37
|
| Rate for Payer: CDPHP Medicare |
$12.58
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$27.20
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$27.20
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$27.20
|
| Rate for Payer: EmblemHealth Medicaid |
$27.20
|
| Rate for Payer: EmblemHealth Medicare |
$11.56
|
| Rate for Payer: EmblemHealth Select Care |
$24.48
|
| Rate for Payer: Fidelis Medicare |
$12.96
|
| Rate for Payer: Galaxy Health Commercial |
$22.10
|
| Rate for Payer: Hamaspik Choice Medicare |
$12.58
|
| Rate for Payer: Humana Medicare |
$12.58
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$23.80
|
| Rate for Payer: Local 1199SEIU Medicare |
$15.64
|
| Rate for Payer: MVP Health Care of NY Commercial |
$25.50
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$19.14
|
| Rate for Payer: MVP Health Care of NY Medicare |
$13.21
|
| Rate for Payer: United Healthcare Medicare |
$12.58
|
| Rate for Payer: WellCare Medicare |
$18.70
|
|
|
LIALDA DR 1.2 GM TABLET 1.2 g, 120 eaches
|
Facility
|
IP
|
$34.00
|
|
|
Service Code
|
NDC 54092047612
|
| Hospital Charge Code |
4401434
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.70 |
| Max. Negotiated Rate |
$22.10 |
| Rate for Payer: Cash Price |
$25.50
|
| Rate for Payer: Galaxy Health Commercial |
$22.10
|
| Rate for Payer: WellCare Medicare |
$18.70
|
|
|
LIDOCAINE 0.05 OINT 35.44 GM
|
Facility
|
IP
|
$927.00
|
|
|
Service Code
|
NDC 50383093335
|
| Hospital Charge Code |
4400437
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$509.85 |
| Max. Negotiated Rate |
$602.55 |
| Rate for Payer: Cash Price |
$695.25
|
| Rate for Payer: Galaxy Health Commercial |
$602.55
|
| Rate for Payer: WellCare Medicare |
$509.85
|
|
|
LIDOCAINE 0.05 OINT 35.44 GM
|
Facility
|
OP
|
$927.00
|
|
|
Service Code
|
NDC 50383093335
|
| Hospital Charge Code |
4400437
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$315.18 |
| Max. Negotiated Rate |
$746.24 |
| Rate for Payer: Aetna of NY Commercial |
$648.90
|
| Rate for Payer: Aetna of NY Medicare |
$426.42
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$695.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$695.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$342.99
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$463.50
|
| Rate for Payer: Cash Price |
$695.25
|
| Rate for Payer: CDPHP Commercial |
$746.24
|
| Rate for Payer: CDPHP Medicare |
$342.99
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$741.60
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$741.60
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$741.60
|
| Rate for Payer: EmblemHealth Medicaid |
$741.60
|
| Rate for Payer: EmblemHealth Medicare |
$315.18
|
| Rate for Payer: EmblemHealth Select Care |
$667.44
|
| Rate for Payer: Fidelis Medicare |
$353.28
|
| Rate for Payer: Galaxy Health Commercial |
$602.55
|
| Rate for Payer: Hamaspik Choice Medicare |
$342.99
|
| Rate for Payer: Humana Medicare |
$342.99
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$648.90
|
| Rate for Payer: Local 1199SEIU Medicare |
$426.42
|
| Rate for Payer: MVP Health Care of NY Commercial |
$695.25
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$521.90
|
| Rate for Payer: MVP Health Care of NY Medicare |
$360.14
|
| Rate for Payer: United Healthcare Medicare |
$342.99
|
| Rate for Payer: WellCare Medicare |
$509.85
|
|
|
LIDOCAINE 0.05 PTCH 30 EA
|
Facility
|
IP
|
$44.03
|
|
|
Service Code
|
NDC 00603188010
|
| Hospital Charge Code |
4400451
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.22 |
| Max. Negotiated Rate |
$28.62 |
| Rate for Payer: Cash Price |
$33.02
|
| Rate for Payer: Galaxy Health Commercial |
$28.62
|
| Rate for Payer: WellCare Medicare |
$24.22
|
|
|
LIDOCAINE 0.05 PTCH 30 EA
|
Facility
|
OP
|
$44.03
|
|
|
Service Code
|
NDC 00603188010
|
| Hospital Charge Code |
4400451
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.97 |
| Max. Negotiated Rate |
$35.44 |
| Rate for Payer: Aetna of NY Commercial |
$30.82
|
| Rate for Payer: Aetna of NY Medicare |
$20.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$33.02
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$33.02
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$16.29
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$22.02
|
| Rate for Payer: Cash Price |
$33.02
|
| Rate for Payer: CDPHP Commercial |
$35.44
|
| Rate for Payer: CDPHP Medicare |
$16.29
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$35.22
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$35.22
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$35.22
|
| Rate for Payer: EmblemHealth Medicaid |
$35.22
|
| Rate for Payer: EmblemHealth Medicare |
$14.97
|
| Rate for Payer: EmblemHealth Select Care |
$31.70
|
| Rate for Payer: Fidelis Medicare |
$16.78
|
| Rate for Payer: Galaxy Health Commercial |
$28.62
|
| Rate for Payer: Hamaspik Choice Medicare |
$16.29
|
| Rate for Payer: Humana Medicare |
$16.29
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$30.82
|
| Rate for Payer: Local 1199SEIU Medicare |
$20.25
|
| Rate for Payer: MVP Health Care of NY Commercial |
$33.02
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$24.79
|
| Rate for Payer: MVP Health Care of NY Medicare |
$17.11
|
| Rate for Payer: United Healthcare Medicare |
$16.29
|
| Rate for Payer: WellCare Medicare |
$24.22
|
|
|
LIDOCAINE 4% CREAM 4 g, 15 g
|
Facility
|
IP
|
$30.00
|
|
|
Service Code
|
NDC 00536126720
|
| Hospital Charge Code |
4401918
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.50 |
| Max. Negotiated Rate |
$19.50 |
| Rate for Payer: Cash Price |
$22.50
|
| Rate for Payer: Galaxy Health Commercial |
$19.50
|
| Rate for Payer: WellCare Medicare |
$16.50
|
|
|
LIDOCAINE 4% CREAM 4 g, 15 g
|
Facility
|
OP
|
$30.00
|
|
|
Service Code
|
NDC 00536126720
|
| Hospital Charge Code |
4401918
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.20 |
| Max. Negotiated Rate |
$24.15 |
| Rate for Payer: Aetna of NY Commercial |
$21.00
|
| Rate for Payer: Aetna of NY Medicare |
$13.80
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$22.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$22.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$11.10
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$15.00
|
| Rate for Payer: Cash Price |
$22.50
|
| Rate for Payer: CDPHP Commercial |
$24.15
|
| Rate for Payer: CDPHP Medicare |
$11.10
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$24.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$24.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$24.00
|
| Rate for Payer: EmblemHealth Medicaid |
$24.00
|
| Rate for Payer: EmblemHealth Medicare |
$10.20
|
| Rate for Payer: EmblemHealth Select Care |
$21.60
|
| Rate for Payer: Fidelis Medicare |
$11.43
|
| Rate for Payer: Galaxy Health Commercial |
$19.50
|
| Rate for Payer: Hamaspik Choice Medicare |
$11.10
|
| Rate for Payer: Humana Medicare |
$11.10
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$21.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$13.80
|
| Rate for Payer: MVP Health Care of NY Commercial |
$22.50
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$16.89
|
| Rate for Payer: MVP Health Care of NY Medicare |
$11.66
|
| Rate for Payer: United Healthcare Medicare |
$11.10
|
| Rate for Payer: WellCare Medicare |
$16.50
|
|
|
LIDOCAINE/EPINEPHRINE 1-0.001% MDV 25X20
|
Facility
|
IP
|
$7.98
|
|
|
Service Code
|
NDC 00409317801
|
| Hospital Charge Code |
4400448
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.39 |
| Max. Negotiated Rate |
$5.19 |
| Rate for Payer: Cash Price |
$5.99
|
| Rate for Payer: Galaxy Health Commercial |
$5.19
|
| Rate for Payer: WellCare Medicare |
$4.39
|
|
|
LIDOCAINE/EPINEPHRINE 1-0.001% MDV 25X20
|
Facility
|
OP
|
$7.98
|
|
|
Service Code
|
NDC 00409317801
|
| Hospital Charge Code |
4400448
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.71 |
| Max. Negotiated Rate |
$6.42 |
| Rate for Payer: Aetna of NY Commercial |
$5.59
|
| Rate for Payer: Aetna of NY Medicare |
$3.67
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$5.98
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$5.98
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$2.95
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$3.99
|
| Rate for Payer: Cash Price |
$5.99
|
| Rate for Payer: CDPHP Commercial |
$6.42
|
| Rate for Payer: CDPHP Medicare |
$2.95
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$6.38
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$6.38
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$6.38
|
| Rate for Payer: EmblemHealth Medicaid |
$6.38
|
| Rate for Payer: EmblemHealth Medicare |
$2.71
|
| Rate for Payer: EmblemHealth Select Care |
$5.75
|
| Rate for Payer: Fidelis Medicare |
$3.04
|
| Rate for Payer: Galaxy Health Commercial |
$5.19
|
| Rate for Payer: Hamaspik Choice Medicare |
$2.95
|
| Rate for Payer: Humana Medicare |
$2.95
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$5.59
|
| Rate for Payer: Local 1199SEIU Medicare |
$3.67
|
| Rate for Payer: MVP Health Care of NY Commercial |
$5.98
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$4.49
|
| Rate for Payer: MVP Health Care of NY Medicare |
$3.10
|
| Rate for Payer: United Healthcare Medicare |
$2.95
|
| Rate for Payer: WellCare Medicare |
$4.39
|
|
