|
Jantoven 5 MG TABLET 5 mg, 100 eaches
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
NDC 832121601
|
| Hospital Charge Code |
4401470
|
|
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 5 MG TABLET 5 mg, 100 eaches
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
NDC 832121601
|
| 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
|
OP
|
$68.77
|
|
|
Service Code
|
NDC 6027701
|
| Hospital Charge Code |
4401573
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.32 |
| Max. Negotiated Rate |
$55.02 |
| 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) Medicare |
$27.51
|
| Rate for Payer: Cash Price |
$51.58
|
| 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 |
$27.51
|
| Rate for Payer: Galaxy Health Commercial |
$44.70
|
| Rate for Payer: Hamaspik Choice Medicare |
$27.51
|
| Rate for Payer: Humana Medicare |
$27.51
|
| 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 |
$28.88
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$10.32
|
| Rate for Payer: United Healthcare Medicare |
$27.51
|
| Rate for Payer: WellCare Medicare |
$37.82
|
|
|
Januvia 100 MG TABLET 100 mg, 1 each
|
Facility
|
IP
|
$68.77
|
|
|
Service Code
|
NDC 6027701
|
| 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 25 MG
|
Facility
|
IP
|
$44.81
|
|
|
Service Code
|
NDC 6022128
|
| 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 6022128
|
| Hospital Charge Code |
4401250
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.72 |
| Max. Negotiated Rate |
$35.85 |
| 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) Medicare |
$17.92
|
| Rate for Payer: Cash Price |
$33.61
|
| 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 |
$17.92
|
| Rate for Payer: Galaxy Health Commercial |
$29.13
|
| Rate for Payer: Hamaspik Choice Medicare |
$17.92
|
| Rate for Payer: Humana Medicare |
$17.92
|
| 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 |
$18.82
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$6.72
|
| Rate for Payer: United Healthcare Medicare |
$17.92
|
| Rate for Payer: WellCare Medicare |
$24.65
|
|
|
JARDIANCE 10 MG TABLET 1 ea, 30 eaches
|
Facility
|
IP
|
$63.00
|
|
|
Service Code
|
NDC 597015230
|
| 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 597015230
|
| Hospital Charge Code |
4401415
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.45 |
| Max. Negotiated Rate |
$50.40 |
| 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) Medicare |
$25.20
|
| Rate for Payer: Cash Price |
$47.25
|
| 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 |
$25.20
|
| Rate for Payer: Galaxy Health Commercial |
$40.95
|
| Rate for Payer: Hamaspik Choice Medicare |
$25.20
|
| Rate for Payer: Humana Medicare |
$25.20
|
| 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 |
$26.46
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$9.45
|
| Rate for Payer: United Healthcare Medicare |
$25.20
|
| Rate for Payer: WellCare Medicare |
$34.65
|
|
|
JARDIANCE 25 MG TABLET 1 ea, 30 eaches
|
Facility
|
IP
|
$63.00
|
|
|
Service Code
|
NDC 597015330
|
| 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
|
|
|
JARDIANCE 25 MG TABLET 1 ea, 30 eaches
|
Facility
|
OP
|
$63.00
|
|
|
Service Code
|
NDC 597015330
|
| Hospital Charge Code |
4401416
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.45 |
| Max. Negotiated Rate |
$50.40 |
| 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) Medicare |
$25.20
|
| Rate for Payer: Cash Price |
$47.25
|
| 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 |
$25.20
|
| Rate for Payer: Galaxy Health Commercial |
$40.95
|
| Rate for Payer: Hamaspik Choice Medicare |
$25.20
|
| Rate for Payer: Humana Medicare |
$25.20
|
| 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 |
$26.46
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$9.45
|
| Rate for Payer: United Healthcare Medicare |
$25.20
|
| Rate for Payer: WellCare Medicare |
$34.65
|
|
|
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
|
|
|
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 |
$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
|
|
|
JMAX DISP ACCESS KIT W/3 REAMERS FINE 98
|
Facility
|
OP
|
$4,589.68
|
|
| Hospital Charge Code |
4479292
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$688.45 |
| Max. Negotiated Rate |
$3,671.74 |
| Rate for Payer: Aetna of NY Commercial |
$3,212.78
|
| Rate for Payer: Aetna of NY Medicare |
$2,111.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$1,835.87
|
| Rate for Payer: Cash Price |
$3,442.26
|
| Rate for Payer: CDPHP Medicare |
$1,698.18
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$3,671.74
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$3,671.74
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$3,671.74
|
| Rate for Payer: EmblemHealth Medicaid |
$3,671.74
|
| Rate for Payer: EmblemHealth Medicare |
$1,560.49
|
| Rate for Payer: EmblemHealth Select Care |
$3,304.57
|
| Rate for Payer: Fidelis Medicare |
$1,835.87
|
| Rate for Payer: Galaxy Health Commercial |
$2,983.29
|
| Rate for Payer: Hamaspik Choice Medicare |
$1,835.87
|
| Rate for Payer: Humana Medicare |
$1,835.87
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$3,212.78
|
| Rate for Payer: Local 1199SEIU Medicare |
$2,111.25
|
| Rate for Payer: MVP Health Care of NY Commercial |
$3,442.26
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$2,583.99
|
| Rate for Payer: MVP Health Care of NY Medicare |
$1,927.67
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$688.45
|
| Rate for Payer: United Healthcare Medicare |
$1,835.87
|
| Rate for Payer: WellCare Medicare |
$2,524.32
|
|
|
JMAX DISP ACCESS KIT W/3 REAMERS FINE 98
|
Facility
|
IP
|
$4,589.68
|
|
| Hospital Charge Code |
4479292
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$2,983.29 |
| Max. Negotiated Rate |
$2,983.29 |
| Rate for Payer: Cash Price |
$3,442.26
|
| Rate for Payer: Galaxy Health Commercial |
$2,983.29
|
|
|
JMAX NEEDLE GUIDE WIRE SET
|
Facility
|
OP
|
$230.72
|
|
| Hospital Charge Code |
4479293
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$34.61 |
| Max. Negotiated Rate |
$184.58 |
| Rate for Payer: Aetna of NY Commercial |
$161.50
|
| Rate for Payer: Aetna of NY Medicare |
$106.13
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$92.29
|
| Rate for Payer: Cash Price |
$173.04
|
| Rate for Payer: CDPHP Medicare |
$85.37
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$184.58
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$184.58
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$184.58
|
| Rate for Payer: EmblemHealth Medicaid |
$184.58
|
| Rate for Payer: EmblemHealth Medicare |
$78.44
|
| Rate for Payer: EmblemHealth Select Care |
$166.12
|
| Rate for Payer: Fidelis Medicare |
$92.29
|
| Rate for Payer: Galaxy Health Commercial |
$149.97
|
| Rate for Payer: Hamaspik Choice Medicare |
$92.29
|
| Rate for Payer: Humana Medicare |
$92.29
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$161.50
|
| Rate for Payer: Local 1199SEIU Medicare |
$106.13
|
| Rate for Payer: MVP Health Care of NY Commercial |
$173.04
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$129.90
|
| Rate for Payer: MVP Health Care of NY Medicare |
$96.90
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$34.61
|
| Rate for Payer: United Healthcare Medicare |
$92.29
|
| Rate for Payer: WellCare Medicare |
$126.90
|
|
|
JMAX NEEDLE GUIDE WIRE SET
|
Facility
|
IP
|
$230.72
|
|
| Hospital Charge Code |
4479293
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$149.97 |
| Max. Negotiated Rate |
$149.97 |
| Rate for Payer: Cash Price |
$173.04
|
| Rate for Payer: Galaxy Health Commercial |
$149.97
|
|
|
JMAX TRIGGER FLEX LOT 13070112A
|
Facility
|
OP
|
$1,334.88
|
|
| Hospital Charge Code |
4479289
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$200.23 |
| Max. Negotiated Rate |
$1,067.90 |
| Rate for Payer: Aetna of NY Commercial |
$934.42
|
| Rate for Payer: Aetna of NY Medicare |
$614.04
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$533.95
|
| Rate for Payer: Cash Price |
$1,001.16
|
| Rate for Payer: CDPHP Medicare |
$493.91
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$1,067.90
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$1,067.90
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$1,067.90
|
| Rate for Payer: EmblemHealth Medicaid |
$1,067.90
|
| Rate for Payer: EmblemHealth Medicare |
$453.86
|
| Rate for Payer: EmblemHealth Select Care |
$961.11
|
| Rate for Payer: Fidelis Medicare |
$533.95
|
| Rate for Payer: Galaxy Health Commercial |
$867.67
|
| Rate for Payer: Hamaspik Choice Medicare |
$533.95
|
| Rate for Payer: Humana Medicare |
$533.95
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$934.42
|
| Rate for Payer: Local 1199SEIU Medicare |
$614.04
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,001.16
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$751.54
|
| Rate for Payer: MVP Health Care of NY Medicare |
$560.65
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$200.23
|
| Rate for Payer: United Healthcare Medicare |
$533.95
|
| Rate for Payer: WellCare Medicare |
$734.18
|
|
|
JMAX TRIGGER FLEX LOT 13070112A
|
Facility
|
IP
|
$1,334.88
|
|
| Hospital Charge Code |
4479289
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$867.67 |
| Max. Negotiated Rate |
$867.67 |
| Rate for Payer: Cash Price |
$1,001.16
|
| Rate for Payer: Galaxy Health Commercial |
$867.67
|
|
|
JMAX TUBING SET JIFP2000 IRRIGATION PUMP
|
Facility
|
IP
|
$167.89
|
|
| Hospital Charge Code |
4479291
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$109.13 |
| Max. Negotiated Rate |
$109.13 |
| Rate for Payer: Cash Price |
$125.92
|
| Rate for Payer: Galaxy Health Commercial |
$109.13
|
|
|
JMAX TUBING SET JIFP2000 IRRIGATION PUMP
|
Facility
|
OP
|
$167.89
|
|
| Hospital Charge Code |
4479291
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$25.18 |
| Max. Negotiated Rate |
$134.31 |
| Rate for Payer: Aetna of NY Commercial |
$117.52
|
| Rate for Payer: Aetna of NY Medicare |
$77.23
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$67.16
|
| Rate for Payer: Cash Price |
$125.92
|
| Rate for Payer: CDPHP Medicare |
$62.12
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$134.31
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$134.31
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$134.31
|
| Rate for Payer: EmblemHealth Medicaid |
$134.31
|
| Rate for Payer: EmblemHealth Medicare |
$57.08
|
| Rate for Payer: EmblemHealth Select Care |
$120.88
|
| Rate for Payer: Fidelis Medicare |
$67.16
|
| Rate for Payer: Galaxy Health Commercial |
$109.13
|
| Rate for Payer: Hamaspik Choice Medicare |
$67.16
|
| Rate for Payer: Humana Medicare |
$67.16
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$117.52
|
| Rate for Payer: Local 1199SEIU Medicare |
$77.23
|
| Rate for Payer: MVP Health Care of NY Commercial |
$125.92
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$94.52
|
| Rate for Payer: MVP Health Care of NY Medicare |
$70.51
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$25.18
|
| Rate for Payer: United Healthcare Medicare |
$67.16
|
| Rate for Payer: WellCare Medicare |
$92.34
|
|
|
JMAX VERTICAL ISOLATION DRAPE D122822
|
Facility
|
IP
|
$167.89
|
|
| Hospital Charge Code |
4479290
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$109.13 |
| Max. Negotiated Rate |
$109.13 |
| Rate for Payer: Cash Price |
$125.92
|
| Rate for Payer: Galaxy Health Commercial |
$109.13
|
|
|
JMAX VERTICAL ISOLATION DRAPE D122822
|
Facility
|
OP
|
$167.89
|
|
| Hospital Charge Code |
4479290
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$25.18 |
| Max. Negotiated Rate |
$134.31 |
| Rate for Payer: Aetna of NY Commercial |
$117.52
|
| Rate for Payer: Aetna of NY Medicare |
$77.23
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$67.16
|
| Rate for Payer: Cash Price |
$125.92
|
| Rate for Payer: CDPHP Medicare |
$62.12
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$134.31
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$134.31
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$134.31
|
| Rate for Payer: EmblemHealth Medicaid |
$134.31
|
| Rate for Payer: EmblemHealth Medicare |
$57.08
|
| Rate for Payer: EmblemHealth Select Care |
$120.88
|
| Rate for Payer: Fidelis Medicare |
$67.16
|
| Rate for Payer: Galaxy Health Commercial |
$109.13
|
| Rate for Payer: Hamaspik Choice Medicare |
$67.16
|
| Rate for Payer: Humana Medicare |
$67.16
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$117.52
|
| Rate for Payer: Local 1199SEIU Medicare |
$77.23
|
| Rate for Payer: MVP Health Care of NY Commercial |
$125.92
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$94.52
|
| Rate for Payer: MVP Health Care of NY Medicare |
$70.51
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$25.18
|
| Rate for Payer: United Healthcare Medicare |
$67.16
|
| Rate for Payer: WellCare Medicare |
$92.34
|
|
|
JT EXCISION PROX END PHALA
|
Facility
|
IP
|
$10,029.00
|
|
|
Service Code
|
HCPCS 28160
|
| Hospital Charge Code |
4853011
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$6,518.85 |
| Max. Negotiated Rate |
$6,518.85 |
| Rate for Payer: Cash Price |
$7,521.75
|
| Rate for Payer: Galaxy Health Commercial |
$6,518.85
|
|
|
JT EXCISION PROX END PHALA
|
Facility
|
OP
|
$10,029.00
|
|
|
Service Code
|
HCPCS 28160
|
| Hospital Charge Code |
4853011
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,504.35 |
| Max. Negotiated Rate |
$8,023.20 |
| Rate for Payer: Aetna of NY Commercial |
$7,020.30
|
| Rate for Payer: Aetna of NY Medicare |
$4,613.34
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$4,011.60
|
| Rate for Payer: Cash Price |
$7,521.75
|
| Rate for Payer: CDPHP Medicare |
$3,710.73
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$8,023.20
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$8,023.20
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$8,023.20
|
| Rate for Payer: EmblemHealth Medicaid |
$8,023.20
|
| Rate for Payer: EmblemHealth Medicare |
$3,409.86
|
| Rate for Payer: EmblemHealth Select Care |
$7,220.88
|
| Rate for Payer: Fidelis Medicare |
$4,011.60
|
| Rate for Payer: Galaxy Health Commercial |
$6,518.85
|
| Rate for Payer: Hamaspik Choice Medicare |
$4,011.60
|
| Rate for Payer: Humana Medicare |
$4,011.60
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$7,020.30
|
| Rate for Payer: Local 1199SEIU Medicare |
$4,613.34
|
| Rate for Payer: MVP Health Care of NY Commercial |
$7,521.75
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$5,646.33
|
| Rate for Payer: MVP Health Care of NY Medicare |
$4,212.18
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$1,504.35
|
| Rate for Payer: United Healthcare Medicare |
$4,011.60
|
| Rate for Payer: WellCare Medicare |
$5,515.95
|
|
|
JUGULAR VENA CAVA FILTER
|
Facility
|
OP
|
$5,706.20
|
|
| Hospital Charge Code |
4471878
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$855.93 |
| Max. Negotiated Rate |
$4,564.96 |
| Rate for Payer: Aetna of NY Commercial |
$3,994.34
|
| Rate for Payer: Aetna of NY Medicare |
$2,624.85
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$2,282.48
|
| Rate for Payer: Cash Price |
$4,279.65
|
| Rate for Payer: CDPHP Medicare |
$2,111.29
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$4,564.96
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$4,564.96
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$4,564.96
|
| Rate for Payer: EmblemHealth Medicaid |
$4,564.96
|
| Rate for Payer: EmblemHealth Medicare |
$1,940.11
|
| Rate for Payer: EmblemHealth Select Care |
$4,108.46
|
| Rate for Payer: Fidelis Medicare |
$2,282.48
|
| Rate for Payer: Galaxy Health Commercial |
$3,709.03
|
| Rate for Payer: Hamaspik Choice Medicare |
$2,282.48
|
| Rate for Payer: Humana Medicare |
$2,282.48
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$3,994.34
|
| Rate for Payer: Local 1199SEIU Medicare |
$2,624.85
|
| Rate for Payer: MVP Health Care of NY Commercial |
$4,279.65
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$3,212.59
|
| Rate for Payer: MVP Health Care of NY Medicare |
$2,396.60
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$855.93
|
| Rate for Payer: United Healthcare Medicare |
$2,282.48
|
| Rate for Payer: WellCare Medicare |
$3,138.41
|
|
