|
levothyroxine 100 MCG TABLET 100 mcg, 100 eaches
|
Facility
|
OP
|
$17.00
|
|
|
Service Code
|
NDC 51079044201
|
| Hospital Charge Code |
4400853
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$13.60 |
| Rate for Payer: Aetna of NY Commercial |
$11.90
|
| Rate for Payer: Aetna of NY Medicare |
$7.82
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$6.80
|
| Rate for Payer: Cash Price |
$12.75
|
| Rate for Payer: CDPHP Medicare |
$6.29
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$13.60
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$13.60
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$13.60
|
| Rate for Payer: EmblemHealth Medicaid |
$13.60
|
| Rate for Payer: EmblemHealth Medicare |
$5.78
|
| Rate for Payer: EmblemHealth Select Care |
$12.24
|
| Rate for Payer: Fidelis Medicare |
$6.80
|
| Rate for Payer: Galaxy Health Commercial |
$11.05
|
| Rate for Payer: Hamaspik Choice Medicare |
$6.80
|
| Rate for Payer: Humana Medicare |
$6.80
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$11.90
|
| Rate for Payer: Local 1199SEIU Medicare |
$7.82
|
| Rate for Payer: MVP Health Care of NY Commercial |
$12.75
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$9.57
|
| Rate for Payer: MVP Health Care of NY Medicare |
$7.14
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$2.55
|
| Rate for Payer: United Healthcare Medicare |
$6.80
|
| Rate for Payer: WellCare Medicare |
$9.35
|
|
|
levothyroxine 112 MCG TABLET 112 mcg, 90 eaches
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
NDC 378181177
|
| 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 112 MCG TABLET 112 mcg, 90 eaches
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
NDC 378181177
|
| Hospital Charge Code |
4401306
|
|
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
|
|
|
levothyroxine 125 MCG TABLET 125 mcg, 100 eaches
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
NDC 51079044320
|
| Hospital Charge Code |
4401298
|
|
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
|
OP
|
$6.00
|
|
|
Service Code
|
NDC 51079044320
|
| Hospital Charge Code |
4401298
|
|
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
|
|
|
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 |
$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
|
|
|
levothyroxine 50 MCG TABLET 50 mcg, 100 eaches
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
NDC 51079044001
|
| Hospital Charge Code |
4401297
|
|
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
|
|
|
levothyroxine 50 MCG TABLET 50 mcg, 100 eaches
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
NDC 51079044001
|
| Hospital Charge Code |
4401297
|
|
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 75 MCG TABLET
|
Facility
|
OP
|
$1.50
|
|
|
Service Code
|
NDC 51079044120
|
| Hospital Charge Code |
4401285
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$1.20 |
| 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) Medicare |
$0.60
|
| Rate for Payer: Cash Price |
$1.12
|
| 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 |
$0.60
|
| Rate for Payer: Galaxy Health Commercial |
$0.98
|
| Rate for Payer: Hamaspik Choice Medicare |
$0.60
|
| Rate for Payer: Humana Medicare |
$0.60
|
| 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 |
$0.63
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$0.23
|
| Rate for Payer: United Healthcare Medicare |
$0.60
|
| 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 |
$1.12
|
| Rate for Payer: Galaxy Health Commercial |
$0.98
|
| 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 |
$0.93 |
| Max. Negotiated Rate |
$4.94 |
| 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) Medicare |
$2.47
|
| Rate for Payer: Cash Price |
$4.64
|
| 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 |
$2.47
|
| Rate for Payer: Galaxy Health Commercial |
$4.02
|
| Rate for Payer: Hamaspik Choice Medicare |
$2.47
|
| Rate for Payer: Humana Medicare |
$2.47
|
| 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 |
$4.63
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$3.48
|
| Rate for Payer: MVP Health Care of NY Medicare |
$2.60
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$0.93
|
| Rate for Payer: United Healthcare Medicare |
$2.47
|
| 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
|
IP
|
$6.00
|
|
|
Service Code
|
NDC 378180077
|
| 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
|
|
|
LEVOTHYROXINE SODIUM
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
NDC 378180077
|
| Hospital Charge Code |
4401286
|
|
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
|
|
|
LEXISCAN .1MG
|
Facility
|
OP
|
$193.64
|
|
|
Service Code
|
HCPCS J2785
|
| Hospital Charge Code |
4211246
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.90 |
| Max. Negotiated Rate |
$154.91 |
| Rate for Payer: Aetna of NY Medicare |
$89.07
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$77.46
|
| Rate for Payer: Cash Price |
$145.23
|
| Rate for Payer: Cash Price |
$145.23
|
| Rate for Payer: CDPHP Medicare |
$71.65
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$2.90
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$154.91
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$154.91
|
| Rate for Payer: EmblemHealth Medicaid |
$154.91
|
| Rate for Payer: EmblemHealth Medicare |
$65.84
|
| Rate for Payer: EmblemHealth Select Care |
$2.90
|
| Rate for Payer: Fidelis Medicare |
$77.46
|
| Rate for Payer: Galaxy Health Commercial |
$125.87
|
| Rate for Payer: Hamaspik Choice Medicare |
$77.46
|
| Rate for Payer: Humana Medicare |
$77.46
|
| Rate for Payer: Local 1199SEIU Medicare |
$89.07
|
| Rate for Payer: MVP Health Care of NY Commercial |
$145.23
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$109.02
|
| Rate for Payer: MVP Health Care of NY Medicare |
$81.33
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$102.76
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$29.05
|
| Rate for Payer: United Healthcare Commercial |
$102.76
|
| Rate for Payer: United Healthcare Medicare |
$77.46
|
| Rate for Payer: WellCare Medicare |
$106.50
|
|
|
LEXISCAN .1MG
|
Facility
|
IP
|
$193.64
|
|
|
Service Code
|
HCPCS J2785
|
| Hospital Charge Code |
4211246
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.90 |
| Max. Negotiated Rate |
$125.87 |
| Rate for Payer: Aetna of NY Commercial |
$106.50
|
| Rate for Payer: Cash Price |
$145.23
|
| Rate for Payer: Cash Price |
$145.23
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$2.90
|
| Rate for Payer: EmblemHealth Select Care |
$2.90
|
| Rate for Payer: Galaxy Health Commercial |
$125.87
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$106.50
|
| Rate for Payer: WellCare Medicare |
$106.50
|
|
|
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 |
$5.10 |
| Max. Negotiated Rate |
$27.20 |
| 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) Medicare |
$13.60
|
| Rate for Payer: Cash Price |
$25.50
|
| 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 |
$13.60
|
| Rate for Payer: Galaxy Health Commercial |
$22.10
|
| Rate for Payer: Hamaspik Choice Medicare |
$13.60
|
| Rate for Payer: Humana Medicare |
$13.60
|
| 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 |
$14.28
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$5.10
|
| Rate for Payer: United Healthcare Medicare |
$13.60
|
| 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 |
$139.05 |
| Max. Negotiated Rate |
$741.60 |
| 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) Medicare |
$370.80
|
| Rate for Payer: Cash Price |
$695.25
|
| 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 |
$370.80
|
| Rate for Payer: Galaxy Health Commercial |
$602.55
|
| Rate for Payer: Hamaspik Choice Medicare |
$370.80
|
| Rate for Payer: Humana Medicare |
$370.80
|
| 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 |
$389.34
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$139.05
|
| Rate for Payer: United Healthcare Medicare |
$370.80
|
| Rate for Payer: WellCare Medicare |
$509.85
|
|
|
LIDOCAINE 0.05 PTCH 30 EA
|
Facility
|
OP
|
$44.03
|
|
|
Service Code
|
NDC 603188010
|
| Hospital Charge Code |
4400451
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.60 |
| Max. Negotiated Rate |
$35.22 |
| 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) Medicare |
$17.61
|
| Rate for Payer: Cash Price |
$33.02
|
| 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 |
$17.61
|
| Rate for Payer: Galaxy Health Commercial |
$28.62
|
| Rate for Payer: Hamaspik Choice Medicare |
$17.61
|
| Rate for Payer: Humana Medicare |
$17.61
|
| 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 |
$18.49
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$6.60
|
| Rate for Payer: United Healthcare Medicare |
$17.61
|
| Rate for Payer: WellCare Medicare |
$24.22
|
|
|
LIDOCAINE 0.05 PTCH 30 EA
|
Facility
|
IP
|
$44.03
|
|
|
Service Code
|
NDC 603188010
|
| 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 4% CREAM 4 g, 15 g
|
Facility
|
IP
|
$30.00
|
|
|
Service Code
|
NDC 536126720
|
| 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 536126720
|
| Hospital Charge Code |
4401918
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.50 |
| Max. Negotiated Rate |
$24.00 |
| 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) Medicare |
$12.00
|
| Rate for Payer: Cash Price |
$22.50
|
| 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 |
$12.00
|
| Rate for Payer: Galaxy Health Commercial |
$19.50
|
| Rate for Payer: Hamaspik Choice Medicare |
$12.00
|
| Rate for Payer: Humana Medicare |
$12.00
|
| 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 |
$12.60
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$4.50
|
| Rate for Payer: United Healthcare Medicare |
$12.00
|
| Rate for Payer: WellCare Medicare |
$16.50
|
|
