|
IV PUMP USAGE
|
Facility
|
OP
|
$20.60
|
|
| Hospital Charge Code |
4451236
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$3.09 |
| Max. Negotiated Rate |
$16.48 |
| Rate for Payer: Aetna of NY Commercial |
$14.42
|
| Rate for Payer: Aetna of NY Medicare |
$9.48
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$8.24
|
| Rate for Payer: Cash Price |
$15.45
|
| Rate for Payer: CDPHP Medicare |
$7.62
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$16.48
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$16.48
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$16.48
|
| Rate for Payer: EmblemHealth Medicaid |
$16.48
|
| Rate for Payer: EmblemHealth Medicare |
$7.00
|
| Rate for Payer: EmblemHealth Select Care |
$14.83
|
| Rate for Payer: Fidelis Medicare |
$8.24
|
| Rate for Payer: Galaxy Health Commercial |
$13.39
|
| Rate for Payer: Hamaspik Choice Medicare |
$8.24
|
| Rate for Payer: Humana Medicare |
$8.24
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$14.42
|
| Rate for Payer: Local 1199SEIU Medicare |
$9.48
|
| Rate for Payer: MVP Health Care of NY Commercial |
$15.45
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$11.60
|
| Rate for Payer: MVP Health Care of NY Medicare |
$8.65
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$3.09
|
| Rate for Payer: United Healthcare Medicare |
$8.24
|
| Rate for Payer: WellCare Medicare |
$11.33
|
|
|
IV PUSH SEQ INJ SAME DRUG ADDITIONAL
|
Facility
|
OP
|
$144.00
|
|
|
Service Code
|
HCPCS 96375
|
| Hospital Charge Code |
4451234
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$21.60 |
| Max. Negotiated Rate |
$115.20 |
| Rate for Payer: Aetna of NY Commercial |
$100.80
|
| Rate for Payer: Aetna of NY Medicare |
$66.24
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$57.60
|
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: CDPHP Medicare |
$53.28
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$115.20
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$115.20
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$115.20
|
| Rate for Payer: EmblemHealth Medicaid |
$115.20
|
| Rate for Payer: EmblemHealth Medicare |
$48.96
|
| Rate for Payer: EmblemHealth Select Care |
$103.68
|
| Rate for Payer: Fidelis Medicare |
$57.60
|
| Rate for Payer: Galaxy Health Commercial |
$93.60
|
| Rate for Payer: Hamaspik Choice Medicare |
$57.60
|
| Rate for Payer: Humana Medicare |
$57.60
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$100.80
|
| Rate for Payer: Local 1199SEIU Medicare |
$66.24
|
| Rate for Payer: MVP Health Care of NY Commercial |
$108.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$81.07
|
| Rate for Payer: MVP Health Care of NY Medicare |
$60.48
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$108.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$21.60
|
| Rate for Payer: United Healthcare Commercial |
$108.00
|
| Rate for Payer: United Healthcare Medicare |
$57.60
|
| Rate for Payer: WellCare Medicare |
$79.20
|
|
|
IV PUSH SEQ INJ SAME DRUG ADDITIONAL
|
Facility
|
IP
|
$144.00
|
|
|
Service Code
|
HCPCS 96375
|
| Hospital Charge Code |
4451234
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$93.60 |
| Max. Negotiated Rate |
$93.60 |
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Galaxy Health Commercial |
$93.60
|
|
|
IV PUSH SUBSEQUENT
|
Facility
|
OP
|
$144.00
|
|
|
Service Code
|
HCPCS 96375
|
| Hospital Charge Code |
4451244
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$21.60 |
| Max. Negotiated Rate |
$115.20 |
| Rate for Payer: Aetna of NY Commercial |
$100.80
|
| Rate for Payer: Aetna of NY Medicare |
$66.24
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$57.60
|
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: CDPHP Medicare |
$53.28
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$115.20
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$115.20
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$115.20
|
| Rate for Payer: EmblemHealth Medicaid |
$115.20
|
| Rate for Payer: EmblemHealth Medicare |
$48.96
|
| Rate for Payer: EmblemHealth Select Care |
$103.68
|
| Rate for Payer: Fidelis Medicare |
$57.60
|
| Rate for Payer: Galaxy Health Commercial |
$93.60
|
| Rate for Payer: Hamaspik Choice Medicare |
$57.60
|
| Rate for Payer: Humana Medicare |
$57.60
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$100.80
|
| Rate for Payer: Local 1199SEIU Medicare |
$66.24
|
| Rate for Payer: MVP Health Care of NY Commercial |
$108.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$81.07
|
| Rate for Payer: MVP Health Care of NY Medicare |
$60.48
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$108.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$21.60
|
| Rate for Payer: United Healthcare Commercial |
$108.00
|
| Rate for Payer: United Healthcare Medicare |
$57.60
|
| Rate for Payer: WellCare Medicare |
$79.20
|
|
|
IV PUSH SUBSEQUENT
|
Facility
|
IP
|
$144.00
|
|
|
Service Code
|
HCPCS 96375
|
| Hospital Charge Code |
4451244
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$93.60 |
| Max. Negotiated Rate |
$93.60 |
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Galaxy Health Commercial |
$93.60
|
|
|
IV SALINE LOC
|
Facility
|
OP
|
$28.84
|
|
| Hospital Charge Code |
4472144
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$4.33 |
| Max. Negotiated Rate |
$23.07 |
| Rate for Payer: Aetna of NY Commercial |
$20.19
|
| Rate for Payer: Aetna of NY Medicare |
$13.27
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$11.54
|
| Rate for Payer: Cash Price |
$21.63
|
| Rate for Payer: CDPHP Medicare |
$10.67
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$23.07
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$23.07
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$23.07
|
| Rate for Payer: EmblemHealth Medicaid |
$23.07
|
| Rate for Payer: EmblemHealth Medicare |
$9.81
|
| Rate for Payer: EmblemHealth Select Care |
$20.76
|
| Rate for Payer: Fidelis Medicare |
$11.54
|
| Rate for Payer: Galaxy Health Commercial |
$18.75
|
| Rate for Payer: Hamaspik Choice Medicare |
$11.54
|
| Rate for Payer: Humana Medicare |
$11.54
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$20.19
|
| Rate for Payer: Local 1199SEIU Medicare |
$13.27
|
| Rate for Payer: MVP Health Care of NY Commercial |
$21.63
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$16.24
|
| Rate for Payer: MVP Health Care of NY Medicare |
$12.11
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$4.33
|
| Rate for Payer: United Healthcare Medicare |
$11.54
|
| Rate for Payer: WellCare Medicare |
$15.86
|
|
|
IV SALINE LOC
|
Facility
|
IP
|
$28.84
|
|
| Hospital Charge Code |
4472144
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$18.75 |
| Max. Negotiated Rate |
$18.75 |
| Rate for Payer: Cash Price |
$21.63
|
| Rate for Payer: Galaxy Health Commercial |
$18.75
|
|
|
IV SUPPLIES SOLUTIONING
|
Facility
|
IP
|
$48.41
|
|
| Hospital Charge Code |
4472184
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$31.47 |
| Max. Negotiated Rate |
$31.47 |
| Rate for Payer: Cash Price |
$36.31
|
| Rate for Payer: Galaxy Health Commercial |
$31.47
|
|
|
IV SUPPLIES SOLUTIONING
|
Facility
|
OP
|
$48.41
|
|
| Hospital Charge Code |
4472184
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$7.26 |
| Max. Negotiated Rate |
$38.73 |
| Rate for Payer: Aetna of NY Commercial |
$33.89
|
| Rate for Payer: Aetna of NY Medicare |
$22.27
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$19.36
|
| Rate for Payer: Cash Price |
$36.31
|
| Rate for Payer: CDPHP Medicare |
$17.91
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$38.73
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$38.73
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$38.73
|
| Rate for Payer: EmblemHealth Medicaid |
$38.73
|
| Rate for Payer: EmblemHealth Medicare |
$16.46
|
| Rate for Payer: EmblemHealth Select Care |
$34.86
|
| Rate for Payer: Fidelis Medicare |
$19.36
|
| Rate for Payer: Galaxy Health Commercial |
$31.47
|
| Rate for Payer: Hamaspik Choice Medicare |
$19.36
|
| Rate for Payer: Humana Medicare |
$19.36
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$33.89
|
| Rate for Payer: Local 1199SEIU Medicare |
$22.27
|
| Rate for Payer: MVP Health Care of NY Commercial |
$36.31
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$27.25
|
| Rate for Payer: MVP Health Care of NY Medicare |
$20.33
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$7.26
|
| Rate for Payer: United Healthcare Medicare |
$19.36
|
| Rate for Payer: WellCare Medicare |
$26.63
|
|
|
IV THERAPY EACH HOUR OVER 1.5 HOURS
|
Facility
|
OP
|
$144.00
|
|
|
Service Code
|
HCPCS 96366
|
| Hospital Charge Code |
4450106
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$21.60 |
| Max. Negotiated Rate |
$510.99 |
| Rate for Payer: Aetna of NY Commercial |
$100.80
|
| Rate for Payer: Aetna of NY Medicare |
$66.24
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$57.60
|
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: CDPHP Medicare |
$53.28
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$115.20
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$285.20
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$237.67
|
| Rate for Payer: EmblemHealth Medicaid |
$237.67
|
| Rate for Payer: EmblemHealth Medicare |
$48.96
|
| Rate for Payer: EmblemHealth Select Care |
$103.68
|
| Rate for Payer: Fidelis Medicare |
$57.60
|
| Rate for Payer: Galaxy Health Commercial |
$93.60
|
| Rate for Payer: Galaxy Health Workers Comp |
$232.92
|
| Rate for Payer: Hamaspik Choice Medicaid |
$237.67
|
| Rate for Payer: Hamaspik Choice Medicare |
$57.60
|
| Rate for Payer: Humana Medicare |
$57.60
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$100.80
|
| Rate for Payer: Local 1199SEIU Medicare |
$66.24
|
| Rate for Payer: MVP Health Care of NY Child Health Plus/Family Health Plus/HARP/Medicaid |
$249.55
|
| Rate for Payer: MVP Health Care of NY Commercial |
$108.00
|
| Rate for Payer: MVP Health Care of NY Essential Plan 1&2 |
$510.99
|
| Rate for Payer: MVP Health Care of NY Essential Plan 3&4 |
$510.99
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$81.07
|
| Rate for Payer: MVP Health Care of NY Medicare |
$60.48
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$108.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$21.60
|
| Rate for Payer: United Healthcare Commercial |
$108.00
|
| Rate for Payer: United Healthcare Medicare |
$57.60
|
| Rate for Payer: WellCare Child Health Plus/Family Health Plus/Medicaid |
$249.55
|
| Rate for Payer: WellCare Medicare |
$79.20
|
|
|
IV THERAPY EACH HOUR OVER 1.5 HOURS
|
Facility
|
IP
|
$144.00
|
|
|
Service Code
|
HCPCS 96366
|
| Hospital Charge Code |
4450106
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$93.60 |
| Max. Negotiated Rate |
$93.60 |
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Galaxy Health Commercial |
$93.60
|
|
|
IV THERAPY INITIAL
|
Facility
|
IP
|
$652.00
|
|
|
Service Code
|
HCPCS 96365
|
| Hospital Charge Code |
4451242
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$423.80 |
| Max. Negotiated Rate |
$423.80 |
| Rate for Payer: Cash Price |
$489.00
|
| Rate for Payer: Galaxy Health Commercial |
$423.80
|
|
|
IV THERAPY INITIAL
|
Facility
|
OP
|
$652.00
|
|
|
Service Code
|
HCPCS 96365
|
| Hospital Charge Code |
4451242
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$97.80 |
| Max. Negotiated Rate |
$521.60 |
| Rate for Payer: Aetna of NY Commercial |
$456.40
|
| Rate for Payer: Aetna of NY Medicare |
$299.92
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$260.80
|
| Rate for Payer: Cash Price |
$489.00
|
| Rate for Payer: CDPHP Medicare |
$241.24
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$521.60
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$521.60
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$521.60
|
| Rate for Payer: EmblemHealth Medicaid |
$521.60
|
| Rate for Payer: EmblemHealth Medicare |
$221.68
|
| Rate for Payer: EmblemHealth Select Care |
$469.44
|
| Rate for Payer: Fidelis Medicare |
$260.80
|
| Rate for Payer: Galaxy Health Commercial |
$423.80
|
| Rate for Payer: Hamaspik Choice Medicare |
$260.80
|
| Rate for Payer: Humana Medicare |
$260.80
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$456.40
|
| Rate for Payer: Local 1199SEIU Medicare |
$299.92
|
| Rate for Payer: MVP Health Care of NY Commercial |
$489.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$367.08
|
| Rate for Payer: MVP Health Care of NY Medicare |
$273.84
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$489.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$97.80
|
| Rate for Payer: United Healthcare Commercial |
$489.00
|
| Rate for Payer: United Healthcare Medicare |
$260.80
|
| Rate for Payer: WellCare Medicare |
$358.60
|
|
|
JACKSON-PRATT WOUND DRAIN 10MM
|
Facility
|
IP
|
$43.26
|
|
| Hospital Charge Code |
4472094
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$28.12 |
| Max. Negotiated Rate |
$28.12 |
| Rate for Payer: Cash Price |
$32.44
|
| Rate for Payer: Galaxy Health Commercial |
$28.12
|
|
|
JACKSON-PRATT WOUND DRAIN 10MM
|
Facility
|
OP
|
$43.26
|
|
| Hospital Charge Code |
4472094
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$6.49 |
| Max. Negotiated Rate |
$34.61 |
| Rate for Payer: Aetna of NY Commercial |
$30.28
|
| Rate for Payer: Aetna of NY Medicare |
$19.90
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$17.30
|
| Rate for Payer: Cash Price |
$32.44
|
| Rate for Payer: CDPHP Medicare |
$16.01
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$34.61
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$34.61
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$34.61
|
| Rate for Payer: EmblemHealth Medicaid |
$34.61
|
| Rate for Payer: EmblemHealth Medicare |
$14.71
|
| Rate for Payer: EmblemHealth Select Care |
$31.15
|
| Rate for Payer: Fidelis Medicare |
$17.30
|
| Rate for Payer: Galaxy Health Commercial |
$28.12
|
| Rate for Payer: Hamaspik Choice Medicare |
$17.30
|
| Rate for Payer: Humana Medicare |
$17.30
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$30.28
|
| Rate for Payer: Local 1199SEIU Medicare |
$19.90
|
| Rate for Payer: MVP Health Care of NY Commercial |
$32.45
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$24.36
|
| Rate for Payer: MVP Health Care of NY Medicare |
$18.17
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$6.49
|
| Rate for Payer: United Healthcare Medicare |
$17.30
|
| Rate for Payer: WellCare Medicare |
$23.79
|
|
|
Jantoven 1 MG TABLET 1 mg, 100 eaches
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
NDC 832121101
|
| Hospital Charge Code |
4401422
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.90 |
| Max. Negotiated Rate |
$4.80 |
| 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) Medicare |
$2.40
|
| Rate for Payer: Cash Price |
$4.50
|
| 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 |
$2.40
|
| Rate for Payer: Galaxy Health Commercial |
$3.90
|
| Rate for Payer: Hamaspik Choice Medicare |
$2.40
|
| Rate for Payer: Humana Medicare |
$2.40
|
| 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 |
$2.52
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$0.90
|
| Rate for Payer: United Healthcare Medicare |
$2.40
|
| Rate for Payer: WellCare Medicare |
$3.30
|
|
|
Jantoven 1 MG TABLET 1 mg, 100 eaches
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
NDC 832121101
|
| Hospital Charge Code |
4401422
|
|
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 2.5 MG TABLET 1 ea, 100 eaches
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
NDC 832121301
|
| Hospital Charge Code |
4401420
|
|
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 2.5 MG TABLET 1 ea, 100 eaches
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
NDC 832121301
|
| Hospital Charge Code |
4401420
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.90 |
| Max. Negotiated Rate |
$4.80 |
| 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) Medicare |
$2.40
|
| Rate for Payer: Cash Price |
$4.50
|
| 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 |
$2.40
|
| Rate for Payer: Galaxy Health Commercial |
$3.90
|
| Rate for Payer: Hamaspik Choice Medicare |
$2.40
|
| Rate for Payer: Humana Medicare |
$2.40
|
| 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 |
$2.52
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$0.90
|
| Rate for Payer: United Healthcare Medicare |
$2.40
|
| Rate for Payer: WellCare Medicare |
$3.30
|
|
|
Jantoven 2 MG TABLET 2 mg, 100 eaches
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
NDC 832121201
|
| Hospital Charge Code |
4401430
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.90 |
| Max. Negotiated Rate |
$4.80 |
| 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) Medicare |
$2.40
|
| Rate for Payer: Cash Price |
$4.50
|
| 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 |
$2.40
|
| Rate for Payer: Galaxy Health Commercial |
$3.90
|
| Rate for Payer: Hamaspik Choice Medicare |
$2.40
|
| Rate for Payer: Humana Medicare |
$2.40
|
| 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 |
$2.52
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$0.90
|
| Rate for Payer: United Healthcare Medicare |
$2.40
|
| Rate for Payer: WellCare Medicare |
$3.30
|
|
|
Jantoven 2 MG TABLET 2 mg, 100 eaches
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
NDC 832121201
|
| 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 3 MG TABLET 1 ea, 1 each
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
NDC 832121489
|
| 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 832121489
|
| Hospital Charge Code |
4401421
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.90 |
| Max. Negotiated Rate |
$4.80 |
| 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) Medicare |
$2.40
|
| Rate for Payer: Cash Price |
$4.50
|
| 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 |
$2.40
|
| Rate for Payer: Galaxy Health Commercial |
$3.90
|
| Rate for Payer: Hamaspik Choice Medicare |
$2.40
|
| Rate for Payer: Humana Medicare |
$2.40
|
| 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 |
$2.52
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$0.90
|
| Rate for Payer: United Healthcare Medicare |
$2.40
|
| Rate for Payer: WellCare Medicare |
$3.30
|
|
|
Jantoven 4MG TABS 100 EA
|
Facility
|
IP
|
$7.47
|
|
|
Service Code
|
NDC 56016875
|
| 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 56016875
|
| Hospital Charge Code |
4400192
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.12 |
| Max. Negotiated Rate |
$5.98 |
| 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) Medicare |
$2.99
|
| Rate for Payer: Cash Price |
$5.60
|
| 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 |
$2.99
|
| Rate for Payer: Galaxy Health Commercial |
$4.86
|
| Rate for Payer: Hamaspik Choice Medicare |
$2.99
|
| Rate for Payer: Humana Medicare |
$2.99
|
| 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 |
$3.14
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$1.12
|
| Rate for Payer: United Healthcare Medicare |
$2.99
|
| Rate for Payer: WellCare Medicare |
$4.11
|
|
