|
ABO AND RH TYPE
|
Facility
|
IP
|
$408.00
|
|
|
Service Code
|
HCPCS 86900
|
| Hospital Charge Code |
4300011
|
|
Hospital Revenue Code
|
309
|
| Min. Negotiated Rate |
$265.20 |
| Max. Negotiated Rate |
$265.20 |
| Rate for Payer: Cash Price |
$306.00
|
| Rate for Payer: Galaxy Health Commercial |
$265.20
|
|
|
ABO GROUP
|
Facility
|
OP
|
$408.00
|
|
|
Service Code
|
HCPCS 86900
|
| Hospital Charge Code |
4300012
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$61.20 |
| Max. Negotiated Rate |
$326.40 |
| Rate for Payer: Aetna of NY Commercial |
$265.20
|
| Rate for Payer: Aetna of NY Medicare |
$187.68
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$163.20
|
| Rate for Payer: Cash Price |
$306.00
|
| Rate for Payer: CDPHP Medicare |
$150.96
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$244.80
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$326.40
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$326.40
|
| Rate for Payer: EmblemHealth Medicaid |
$326.40
|
| Rate for Payer: EmblemHealth Medicare |
$138.72
|
| Rate for Payer: EmblemHealth Select Care |
$244.80
|
| Rate for Payer: Fidelis Medicare |
$163.20
|
| Rate for Payer: Galaxy Health Commercial |
$265.20
|
| Rate for Payer: Hamaspik Choice Medicare |
$163.20
|
| Rate for Payer: Humana Medicare |
$163.20
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$265.20
|
| Rate for Payer: Local 1199SEIU Medicare |
$187.68
|
| Rate for Payer: MVP Health Care of NY Commercial |
$306.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$229.70
|
| Rate for Payer: MVP Health Care of NY Medicare |
$171.36
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$306.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$61.20
|
| Rate for Payer: United Healthcare Commercial |
$306.00
|
| Rate for Payer: United Healthcare Medicare |
$163.20
|
| Rate for Payer: WellCare Medicare |
$224.40
|
|
|
ABO GROUP
|
Facility
|
IP
|
$408.00
|
|
|
Service Code
|
HCPCS 86900
|
| Hospital Charge Code |
4300012
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$265.20 |
| Max. Negotiated Rate |
$265.20 |
| Rate for Payer: Cash Price |
$306.00
|
| Rate for Payer: Galaxy Health Commercial |
$265.20
|
|
|
AB; PARVOVIRUS
|
Facility
|
OP
|
$45.00
|
|
|
Service Code
|
HCPCS 86747
|
| Hospital Charge Code |
4304881
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$6.75 |
| Max. Negotiated Rate |
$36.00 |
| Rate for Payer: Aetna of NY Commercial |
$29.25
|
| Rate for Payer: Aetna of NY Medicare |
$20.70
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$18.00
|
| Rate for Payer: Cash Price |
$33.75
|
| Rate for Payer: CDPHP Medicare |
$16.65
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$27.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$36.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$36.00
|
| Rate for Payer: EmblemHealth Medicaid |
$36.00
|
| Rate for Payer: EmblemHealth Medicare |
$15.30
|
| Rate for Payer: EmblemHealth Select Care |
$27.00
|
| Rate for Payer: Fidelis Medicare |
$18.00
|
| Rate for Payer: Galaxy Health Commercial |
$29.25
|
| Rate for Payer: Hamaspik Choice Medicare |
$18.00
|
| Rate for Payer: Humana Medicare |
$18.00
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$29.25
|
| Rate for Payer: Local 1199SEIU Medicare |
$20.70
|
| Rate for Payer: MVP Health Care of NY Commercial |
$33.75
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$25.34
|
| Rate for Payer: MVP Health Care of NY Medicare |
$18.90
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$33.75
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$6.75
|
| Rate for Payer: United Healthcare Commercial |
$33.75
|
| Rate for Payer: United Healthcare Medicare |
$18.00
|
| Rate for Payer: WellCare Medicare |
$24.75
|
|
|
AB; PARVOVIRUS
|
Facility
|
IP
|
$45.00
|
|
|
Service Code
|
HCPCS 86747
|
| Hospital Charge Code |
4304881
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$29.25 |
| Max. Negotiated Rate |
$29.25 |
| Rate for Payer: Cash Price |
$33.75
|
| Rate for Payer: Galaxy Health Commercial |
$29.25
|
|
|
ABP MONITORING 24+ HRS; RECORDING
|
Facility
|
OP
|
$408.00
|
|
|
Service Code
|
HCPCS 93786
|
| Hospital Charge Code |
4480039
|
|
Hospital Revenue Code
|
920
|
| Min. Negotiated Rate |
$61.20 |
| Max. Negotiated Rate |
$326.40 |
| Rate for Payer: Aetna of NY Commercial |
$285.60
|
| Rate for Payer: Aetna of NY Medicare |
$187.68
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$163.20
|
| Rate for Payer: Cash Price |
$306.00
|
| Rate for Payer: CDPHP Medicare |
$150.96
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$285.60
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$326.40
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$326.40
|
| Rate for Payer: EmblemHealth Medicaid |
$326.40
|
| Rate for Payer: EmblemHealth Medicare |
$138.72
|
| Rate for Payer: EmblemHealth Select Care |
$265.20
|
| Rate for Payer: Fidelis Medicare |
$163.20
|
| Rate for Payer: Galaxy Health Commercial |
$265.20
|
| Rate for Payer: Hamaspik Choice Medicare |
$163.20
|
| Rate for Payer: Humana Medicare |
$163.20
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$285.60
|
| Rate for Payer: Local 1199SEIU Medicare |
$187.68
|
| Rate for Payer: MVP Health Care of NY Commercial |
$306.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$229.70
|
| Rate for Payer: MVP Health Care of NY Medicare |
$171.36
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$306.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$61.20
|
| Rate for Payer: United Healthcare Commercial |
$306.00
|
| Rate for Payer: United Healthcare Medicare |
$163.20
|
| Rate for Payer: WellCare Medicare |
$224.40
|
|
|
ABP MONITORING 24+ HRS; RECORDING
|
Facility
|
IP
|
$408.00
|
|
|
Service Code
|
HCPCS 93786
|
| Hospital Charge Code |
4480039
|
|
Hospital Revenue Code
|
920
|
| Min. Negotiated Rate |
$265.20 |
| Max. Negotiated Rate |
$265.20 |
| Rate for Payer: Cash Price |
$306.00
|
| Rate for Payer: Galaxy Health Commercial |
$265.20
|
|
|
ABP MONITORING 24+ HRS; SCANNING ANALYSIS
|
Facility
|
IP
|
$408.00
|
|
|
Service Code
|
HCPCS 93788
|
| Hospital Charge Code |
4480089
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$265.20 |
| Max. Negotiated Rate |
$265.20 |
| Rate for Payer: Cash Price |
$306.00
|
| Rate for Payer: Galaxy Health Commercial |
$265.20
|
|
|
ABP MONITORING 24+ HRS; SCANNING ANALYSIS
|
Facility
|
OP
|
$408.00
|
|
|
Service Code
|
HCPCS 93788
|
| Hospital Charge Code |
4480089
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$61.20 |
| Max. Negotiated Rate |
$326.40 |
| Rate for Payer: Aetna of NY Commercial |
$285.60
|
| Rate for Payer: Aetna of NY Medicare |
$187.68
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$163.20
|
| Rate for Payer: Cash Price |
$306.00
|
| Rate for Payer: CDPHP Medicare |
$150.96
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$285.60
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$326.40
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$326.40
|
| Rate for Payer: EmblemHealth Medicaid |
$326.40
|
| Rate for Payer: EmblemHealth Medicare |
$138.72
|
| Rate for Payer: EmblemHealth Select Care |
$265.20
|
| Rate for Payer: Fidelis Medicare |
$163.20
|
| Rate for Payer: Galaxy Health Commercial |
$265.20
|
| Rate for Payer: Hamaspik Choice Medicare |
$163.20
|
| Rate for Payer: Humana Medicare |
$163.20
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$285.60
|
| Rate for Payer: Local 1199SEIU Medicare |
$187.68
|
| Rate for Payer: MVP Health Care of NY Commercial |
$306.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$229.70
|
| Rate for Payer: MVP Health Care of NY Medicare |
$171.36
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$306.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$61.20
|
| Rate for Payer: United Healthcare Commercial |
$306.00
|
| Rate for Payer: United Healthcare Medicare |
$163.20
|
| Rate for Payer: WellCare Medicare |
$224.40
|
|
|
ABSCESS DRAINAGE UNDER X-RAY
|
Facility
|
IP
|
$429.00
|
|
|
Service Code
|
HCPCS 75989 TC
|
| Hospital Charge Code |
4220005
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$278.85 |
| Max. Negotiated Rate |
$278.85 |
| Rate for Payer: Cash Price |
$321.75
|
| Rate for Payer: Galaxy Health Commercial |
$278.85
|
|
|
ABSCESS DRAINAGE UNDER X-RAY
|
Facility
|
OP
|
$171.00
|
|
|
Service Code
|
HCPCS 75989 26
|
| Hospital Charge Code |
5220005
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$25.65 |
| Max. Negotiated Rate |
$1,076.00 |
| Rate for Payer: Aetna of NY Commercial |
$1,076.00
|
| Rate for Payer: Aetna of NY Medicare |
$78.66
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$68.40
|
| Rate for Payer: Cash Price |
$128.25
|
| Rate for Payer: Cash Price |
$128.25
|
| Rate for Payer: CDPHP Medicare |
$63.27
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$136.80
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$136.80
|
| Rate for Payer: EmblemHealth Medicaid |
$136.80
|
| Rate for Payer: EmblemHealth Medicare |
$58.14
|
| Rate for Payer: Fidelis Medicare |
$68.40
|
| Rate for Payer: Galaxy Health Commercial |
$111.15
|
| Rate for Payer: Hamaspik Choice Medicare |
$68.40
|
| Rate for Payer: Humana Medicare |
$68.40
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,076.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$78.66
|
| Rate for Payer: MVP Health Care of NY Commercial |
$128.25
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$96.27
|
| Rate for Payer: MVP Health Care of NY Medicare |
$71.82
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$25.65
|
| Rate for Payer: United Healthcare Medicare |
$68.40
|
| Rate for Payer: WellCare Medicare |
$94.05
|
|
|
ABSCESS DRAINAGE UNDER X-RAY
|
Facility
|
OP
|
$429.00
|
|
|
Service Code
|
HCPCS 75989 TC
|
| Hospital Charge Code |
4220005
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$64.35 |
| Max. Negotiated Rate |
$1,076.00 |
| Rate for Payer: Aetna of NY Commercial |
$1,076.00
|
| Rate for Payer: Aetna of NY Medicare |
$197.34
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$171.60
|
| Rate for Payer: Cash Price |
$321.75
|
| Rate for Payer: Cash Price |
$321.75
|
| Rate for Payer: Cash Price |
$321.75
|
| Rate for Payer: CDPHP Medicare |
$158.73
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$300.30
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$343.20
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$343.20
|
| Rate for Payer: EmblemHealth Medicaid |
$343.20
|
| Rate for Payer: EmblemHealth Medicare |
$145.86
|
| Rate for Payer: EmblemHealth Select Care |
$278.85
|
| Rate for Payer: Fidelis Medicare |
$171.60
|
| Rate for Payer: Galaxy Health Commercial |
$278.85
|
| Rate for Payer: Hamaspik Choice Medicare |
$171.60
|
| Rate for Payer: Humana Medicare |
$171.60
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,076.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$197.34
|
| Rate for Payer: MVP Health Care of NY Commercial |
$321.75
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$241.53
|
| Rate for Payer: MVP Health Care of NY Medicare |
$180.18
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$798.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$64.35
|
| Rate for Payer: United Healthcare Commercial |
$798.00
|
| Rate for Payer: United Healthcare Medicare |
$171.60
|
| Rate for Payer: WellCare Medicare |
$235.95
|
|
|
ABSCESS DRAINAGE UNDER X-RAY
|
Facility
|
IP
|
$171.00
|
|
|
Service Code
|
HCPCS 75989 26
|
| Hospital Charge Code |
5220005
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$111.15 |
| Max. Negotiated Rate |
$111.15 |
| Rate for Payer: Cash Price |
$128.25
|
| Rate for Payer: Galaxy Health Commercial |
$111.15
|
|
|
ACCESS SYS KII OPTCL THRD 5MMX
|
Facility
|
OP
|
$67.98
|
|
| Hospital Charge Code |
4471821
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$10.20 |
| Max. Negotiated Rate |
$54.38 |
| Rate for Payer: Aetna of NY Commercial |
$47.59
|
| Rate for Payer: Aetna of NY Medicare |
$31.27
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$27.19
|
| Rate for Payer: Cash Price |
$50.98
|
| Rate for Payer: CDPHP Medicare |
$25.15
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$54.38
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$54.38
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$54.38
|
| Rate for Payer: EmblemHealth Medicaid |
$54.38
|
| Rate for Payer: EmblemHealth Medicare |
$23.11
|
| Rate for Payer: EmblemHealth Select Care |
$48.95
|
| Rate for Payer: Fidelis Medicare |
$27.19
|
| Rate for Payer: Galaxy Health Commercial |
$44.19
|
| Rate for Payer: Hamaspik Choice Medicare |
$27.19
|
| Rate for Payer: Humana Medicare |
$27.19
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$47.59
|
| Rate for Payer: Local 1199SEIU Medicare |
$31.27
|
| Rate for Payer: MVP Health Care of NY Commercial |
$50.98
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$38.27
|
| Rate for Payer: MVP Health Care of NY Medicare |
$28.55
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$10.20
|
| Rate for Payer: United Healthcare Medicare |
$27.19
|
| Rate for Payer: WellCare Medicare |
$37.39
|
|
|
ACCESS SYS KII OPTCL THRD 5MMX
|
Facility
|
IP
|
$67.98
|
|
| Hospital Charge Code |
4471821
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$44.19 |
| Max. Negotiated Rate |
$44.19 |
| Rate for Payer: Cash Price |
$50.98
|
| Rate for Payer: Galaxy Health Commercial |
$44.19
|
|
|
ACEPHEN SUPPOS 650 MG
|
Facility
|
IP
|
$6.18
|
|
|
Service Code
|
NDC 45802073000
|
| Hospital Charge Code |
4408948
|
|
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
|
|
|
ACEPHEN SUPPOS 650 MG
|
Facility
|
OP
|
$6.18
|
|
|
Service Code
|
NDC 45802073000
|
| Hospital Charge Code |
4408948
|
|
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
|
|
|
ACETAMIN/BUTALB/CAFF 325-50-40MG TABS 10
|
Facility
|
OP
|
$6.18
|
|
|
Service Code
|
NDC 68084039601
|
| Hospital Charge Code |
4400003
|
|
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
|
|
|
ACETAMIN/BUTALB/CAFF 325-50-40MG TABS 10
|
Facility
|
IP
|
$6.18
|
|
|
Service Code
|
NDC 68084039601
|
| Hospital Charge Code |
4400003
|
|
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
|
|
|
ACETAMINOPHEN
|
Facility
|
OP
|
$360.00
|
|
|
Service Code
|
HCPCS G0480
|
| Hospital Charge Code |
4300014
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$54.00 |
| Max. Negotiated Rate |
$288.00 |
| Rate for Payer: Aetna of NY Commercial |
$234.00
|
| Rate for Payer: Aetna of NY Medicare |
$165.60
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$144.00
|
| Rate for Payer: Cash Price |
$270.00
|
| Rate for Payer: CDPHP Medicare |
$133.20
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$216.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$288.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$288.00
|
| Rate for Payer: EmblemHealth Medicaid |
$288.00
|
| Rate for Payer: EmblemHealth Medicare |
$122.40
|
| Rate for Payer: EmblemHealth Select Care |
$216.00
|
| Rate for Payer: Fidelis Medicare |
$144.00
|
| Rate for Payer: Galaxy Health Commercial |
$234.00
|
| Rate for Payer: Hamaspik Choice Medicare |
$144.00
|
| Rate for Payer: Humana Medicare |
$144.00
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$234.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$165.60
|
| Rate for Payer: MVP Health Care of NY Commercial |
$270.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$202.68
|
| Rate for Payer: MVP Health Care of NY Medicare |
$151.20
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$270.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$54.00
|
| Rate for Payer: United Healthcare Commercial |
$270.00
|
| Rate for Payer: United Healthcare Medicare |
$144.00
|
| Rate for Payer: WellCare Medicare |
$198.00
|
|
|
ACETAMINOPHEN
|
Facility
|
IP
|
$360.00
|
|
|
Service Code
|
HCPCS G0480
|
| Hospital Charge Code |
4300014
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$234.00 |
| Max. Negotiated Rate |
$234.00 |
| Rate for Payer: Cash Price |
$270.00
|
| Rate for Payer: Galaxy Health Commercial |
$234.00
|
|
|
ACETAMINOPHEN 1000MG/100ML BAG 10 mg, 100 mL
|
Facility
|
OP
|
$26.00
|
|
|
Service Code
|
NDC 264410090
|
| Hospital Charge Code |
4401541
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.90 |
| Max. Negotiated Rate |
$20.80 |
| Rate for Payer: Aetna of NY Commercial |
$18.20
|
| Rate for Payer: Aetna of NY Medicare |
$11.96
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$10.40
|
| Rate for Payer: Cash Price |
$19.50
|
| Rate for Payer: CDPHP Medicare |
$9.62
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$20.80
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$20.80
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$20.80
|
| Rate for Payer: EmblemHealth Medicaid |
$20.80
|
| Rate for Payer: EmblemHealth Medicare |
$8.84
|
| Rate for Payer: EmblemHealth Select Care |
$18.72
|
| Rate for Payer: Fidelis Medicare |
$10.40
|
| Rate for Payer: Galaxy Health Commercial |
$16.90
|
| Rate for Payer: Hamaspik Choice Medicare |
$10.40
|
| Rate for Payer: Humana Medicare |
$10.40
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$18.20
|
| Rate for Payer: Local 1199SEIU Medicare |
$11.96
|
| Rate for Payer: MVP Health Care of NY Commercial |
$19.50
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$14.64
|
| Rate for Payer: MVP Health Care of NY Medicare |
$10.92
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$3.90
|
| Rate for Payer: United Healthcare Medicare |
$10.40
|
| Rate for Payer: WellCare Medicare |
$14.30
|
|
|
ACETAMINOPHEN 1000MG/100ML BAG 10 mg, 100 mL
|
Facility
|
IP
|
$26.00
|
|
|
Service Code
|
NDC 264410090
|
| Hospital Charge Code |
4401541
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.30 |
| Max. Negotiated Rate |
$16.90 |
| Rate for Payer: Cash Price |
$19.50
|
| Rate for Payer: Galaxy Health Commercial |
$16.90
|
| Rate for Payer: WellCare Medicare |
$14.30
|
|
|
ACETAMINOPHEN 120MG SUPP 12 EA
|
Facility
|
IP
|
$6.18
|
|
|
Service Code
|
NDC 45802073230
|
| Hospital Charge Code |
4400005
|
|
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
|
|
|
ACETAMINOPHEN 120MG SUPP 12 EA
|
Facility
|
OP
|
$6.18
|
|
|
Service Code
|
NDC 45802073230
|
| Hospital Charge Code |
4400005
|
|
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
|
|
