|
ACETYLCYSTEINE INJECTION 100 MG
|
Facility
|
OP
|
$10.50
|
|
|
Service Code
|
HCPCS J0132
|
| Hospital Charge Code |
4400004
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.77 |
| Max. Negotiated Rate |
$8.45 |
| Rate for Payer: Aetna of NY Commercial |
$5.78
|
| Rate for Payer: Aetna of NY Medicare |
$4.83
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$0.77
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$0.77
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$3.88
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$5.25
|
| Rate for Payer: Cash Price |
$7.88
|
| Rate for Payer: Cash Price |
$7.88
|
| Rate for Payer: CDPHP Commercial |
$8.45
|
| Rate for Payer: CDPHP Medicare |
$3.88
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$0.77
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$8.40
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$8.40
|
| Rate for Payer: EmblemHealth Medicaid |
$8.40
|
| Rate for Payer: EmblemHealth Medicare |
$3.57
|
| Rate for Payer: EmblemHealth Select Care |
$0.77
|
| Rate for Payer: Fidelis Medicare |
$4.00
|
| Rate for Payer: Galaxy Health Commercial |
$6.82
|
| Rate for Payer: Hamaspik Choice Medicare |
$3.88
|
| Rate for Payer: Humana Medicare |
$3.88
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$5.78
|
| Rate for Payer: Local 1199SEIU Medicare |
$4.83
|
| Rate for Payer: MVP Health Care of NY Commercial |
$7.88
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$5.91
|
| Rate for Payer: MVP Health Care of NY Medicare |
$4.08
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$1.29
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$0.77
|
| Rate for Payer: United Healthcare Commercial |
$1.29
|
| Rate for Payer: United Healthcare Medicare |
$3.88
|
| Rate for Payer: WellCare Medicare |
$5.78
|
|
|
ACETYLCYSTEINE INJECTION 100 MG
|
Facility
|
IP
|
$10.50
|
|
|
Service Code
|
HCPCS J0132
|
| Hospital Charge Code |
4400004
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.77 |
| Max. Negotiated Rate |
$6.82 |
| Rate for Payer: Aetna of NY Commercial |
$5.78
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$0.77
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$0.77
|
| Rate for Payer: Cash Price |
$7.88
|
| Rate for Payer: Cash Price |
$7.88
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$0.77
|
| Rate for Payer: EmblemHealth Select Care |
$0.77
|
| Rate for Payer: Galaxy Health Commercial |
$6.82
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$5.78
|
| Rate for Payer: WellCare Medicare |
$5.78
|
|
|
ACID FAST SMEAR
|
Facility
|
IP
|
$21.00
|
|
|
Service Code
|
HCPCS 87206
|
| Hospital Charge Code |
4300019
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$13.65 |
| Max. Negotiated Rate |
$13.65 |
| Rate for Payer: Cash Price |
$15.75
|
| Rate for Payer: Galaxy Health Commercial |
$13.65
|
|
|
ACID FAST SMEAR
|
Facility
|
OP
|
$21.00
|
|
|
Service Code
|
HCPCS 87206
|
| Hospital Charge Code |
4300019
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$5.39 |
| Max. Negotiated Rate |
$16.90 |
| Rate for Payer: Aetna of NY Commercial |
$13.65
|
| Rate for Payer: Aetna of NY Medicare |
$9.66
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$15.75
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$15.75
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$7.77
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$10.50
|
| Rate for Payer: Cash Price |
$15.75
|
| Rate for Payer: Cash Price |
$15.75
|
| Rate for Payer: CDPHP Commercial |
$16.90
|
| Rate for Payer: CDPHP Medicare |
$7.77
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$12.60
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$16.80
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$16.80
|
| Rate for Payer: EmblemHealth Medicaid |
$16.80
|
| Rate for Payer: EmblemHealth Medicare |
$7.14
|
| Rate for Payer: EmblemHealth Select Care |
$12.60
|
| Rate for Payer: Fidelis Medicare |
$8.00
|
| Rate for Payer: Galaxy Health Commercial |
$13.65
|
| Rate for Payer: Hamaspik Choice Medicare |
$7.77
|
| Rate for Payer: Humana Medicare |
$7.77
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$13.65
|
| Rate for Payer: Local 1199SEIU Medicare |
$9.66
|
| Rate for Payer: MVP Health Care of NY Commercial |
$15.75
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$11.82
|
| Rate for Payer: MVP Health Care of NY Medicare |
$8.16
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$15.75
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$5.39
|
| Rate for Payer: United Healthcare Commercial |
$15.75
|
| Rate for Payer: United Healthcare Medicare |
$7.77
|
| Rate for Payer: WellCare Medicare |
$11.55
|
|
|
ACTH
|
Facility
|
OP
|
$269.00
|
|
|
Service Code
|
HCPCS 82024
|
| Hospital Charge Code |
4300021
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$38.62 |
| Max. Negotiated Rate |
$216.54 |
| Rate for Payer: Aetna of NY Commercial |
$174.85
|
| Rate for Payer: Aetna of NY Medicare |
$123.74
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$201.75
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$201.75
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$99.53
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$134.50
|
| Rate for Payer: Cash Price |
$201.75
|
| Rate for Payer: Cash Price |
$201.75
|
| Rate for Payer: CDPHP Commercial |
$216.54
|
| Rate for Payer: CDPHP Medicare |
$99.53
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$161.40
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$215.20
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$215.20
|
| Rate for Payer: EmblemHealth Medicaid |
$215.20
|
| Rate for Payer: EmblemHealth Medicare |
$91.46
|
| Rate for Payer: EmblemHealth Select Care |
$161.40
|
| Rate for Payer: Fidelis Medicare |
$102.52
|
| Rate for Payer: Galaxy Health Commercial |
$174.85
|
| Rate for Payer: Hamaspik Choice Medicare |
$99.53
|
| Rate for Payer: Humana Medicare |
$99.53
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$174.85
|
| Rate for Payer: Local 1199SEIU Medicare |
$123.74
|
| Rate for Payer: MVP Health Care of NY Commercial |
$201.75
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$151.45
|
| Rate for Payer: MVP Health Care of NY Medicare |
$104.51
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$201.75
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$38.62
|
| Rate for Payer: United Healthcare Commercial |
$201.75
|
| Rate for Payer: United Healthcare Medicare |
$99.53
|
| Rate for Payer: WellCare Medicare |
$147.95
|
|
|
ACTH
|
Facility
|
IP
|
$269.00
|
|
|
Service Code
|
HCPCS 82024
|
| Hospital Charge Code |
4300021
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$174.85 |
| Max. Negotiated Rate |
$174.85 |
| Rate for Payer: Cash Price |
$201.75
|
| Rate for Payer: Galaxy Health Commercial |
$174.85
|
|
|
ACTIVATED CHARCOAL 50GM LIQD 240 ML
|
Facility
|
IP
|
$73.13
|
|
|
Service Code
|
NDC 00574012176
|
| Hospital Charge Code |
4400015
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$40.22 |
| Max. Negotiated Rate |
$47.53 |
| Rate for Payer: Cash Price |
$54.85
|
| Rate for Payer: Galaxy Health Commercial |
$47.53
|
| Rate for Payer: WellCare Medicare |
$40.22
|
|
|
ACTIVATED CHARCOAL 50GM LIQD 240 ML
|
Facility
|
OP
|
$73.13
|
|
|
Service Code
|
NDC 00574012176
|
| Hospital Charge Code |
4400015
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.86 |
| Max. Negotiated Rate |
$58.87 |
| Rate for Payer: Aetna of NY Commercial |
$51.19
|
| Rate for Payer: Aetna of NY Medicare |
$33.64
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$54.85
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$54.85
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$27.06
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$36.56
|
| Rate for Payer: Cash Price |
$54.85
|
| Rate for Payer: CDPHP Commercial |
$58.87
|
| Rate for Payer: CDPHP Medicare |
$27.06
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$58.50
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$58.50
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$58.50
|
| Rate for Payer: EmblemHealth Medicaid |
$58.50
|
| Rate for Payer: EmblemHealth Medicare |
$24.86
|
| Rate for Payer: EmblemHealth Select Care |
$52.65
|
| Rate for Payer: Fidelis Medicare |
$27.87
|
| Rate for Payer: Galaxy Health Commercial |
$47.53
|
| Rate for Payer: Hamaspik Choice Medicare |
$27.06
|
| Rate for Payer: Humana Medicare |
$27.06
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$51.19
|
| Rate for Payer: Local 1199SEIU Medicare |
$33.64
|
| Rate for Payer: MVP Health Care of NY Commercial |
$54.85
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$41.17
|
| Rate for Payer: MVP Health Care of NY Medicare |
$28.41
|
| Rate for Payer: United Healthcare Medicare |
$27.06
|
| Rate for Payer: WellCare Medicare |
$40.22
|
|
|
ACTOS 15 MG
|
Facility
|
OP
|
$21.05
|
|
|
Service Code
|
NDC 00781542092
|
| Hospital Charge Code |
4409012
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.16 |
| Max. Negotiated Rate |
$16.95 |
| Rate for Payer: Aetna of NY Commercial |
$14.74
|
| Rate for Payer: Aetna of NY Medicare |
$9.68
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$15.79
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$15.79
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$7.79
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$10.52
|
| Rate for Payer: Cash Price |
$15.79
|
| Rate for Payer: CDPHP Commercial |
$16.95
|
| Rate for Payer: CDPHP Medicare |
$7.79
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$16.84
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$16.84
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$16.84
|
| Rate for Payer: EmblemHealth Medicaid |
$16.84
|
| Rate for Payer: EmblemHealth Medicare |
$7.16
|
| Rate for Payer: EmblemHealth Select Care |
$15.16
|
| Rate for Payer: Fidelis Medicare |
$8.02
|
| Rate for Payer: Galaxy Health Commercial |
$13.68
|
| Rate for Payer: Hamaspik Choice Medicare |
$7.79
|
| Rate for Payer: Humana Medicare |
$7.79
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$14.74
|
| Rate for Payer: Local 1199SEIU Medicare |
$9.68
|
| Rate for Payer: MVP Health Care of NY Commercial |
$15.79
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$11.85
|
| Rate for Payer: MVP Health Care of NY Medicare |
$8.18
|
| Rate for Payer: United Healthcare Medicare |
$7.79
|
| Rate for Payer: WellCare Medicare |
$11.58
|
|
|
ACTOS 15 MG
|
Facility
|
IP
|
$21.05
|
|
|
Service Code
|
NDC 00781542092
|
| Hospital Charge Code |
4409012
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.58 |
| Max. Negotiated Rate |
$13.68 |
| Rate for Payer: Cash Price |
$15.79
|
| Rate for Payer: Galaxy Health Commercial |
$13.68
|
| Rate for Payer: WellCare Medicare |
$11.58
|
|
|
ACUTE HEPATITIS PANEL
|
Facility
|
OP
|
$242.00
|
|
|
Service Code
|
HCPCS 80074
|
| Hospital Charge Code |
4300022
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$47.63 |
| Max. Negotiated Rate |
$194.81 |
| Rate for Payer: Aetna of NY Commercial |
$157.30
|
| Rate for Payer: Aetna of NY Medicare |
$111.32
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$181.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$181.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$89.54
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$121.00
|
| Rate for Payer: Cash Price |
$181.50
|
| Rate for Payer: Cash Price |
$181.50
|
| Rate for Payer: CDPHP Commercial |
$194.81
|
| Rate for Payer: CDPHP Medicare |
$89.54
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$145.20
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$193.60
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$193.60
|
| Rate for Payer: EmblemHealth Medicaid |
$193.60
|
| Rate for Payer: EmblemHealth Medicare |
$82.28
|
| Rate for Payer: EmblemHealth Select Care |
$145.20
|
| Rate for Payer: Fidelis Medicare |
$92.23
|
| Rate for Payer: Galaxy Health Commercial |
$157.30
|
| Rate for Payer: Hamaspik Choice Medicare |
$89.54
|
| Rate for Payer: Humana Medicare |
$89.54
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$157.30
|
| Rate for Payer: Local 1199SEIU Medicare |
$111.32
|
| Rate for Payer: MVP Health Care of NY Commercial |
$181.50
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$136.25
|
| Rate for Payer: MVP Health Care of NY Medicare |
$94.02
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$181.50
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$47.63
|
| Rate for Payer: United Healthcare Commercial |
$181.50
|
| Rate for Payer: United Healthcare Medicare |
$89.54
|
| Rate for Payer: WellCare Medicare |
$133.10
|
|
|
ACUTE HEPATITIS PANEL
|
Facility
|
IP
|
$242.00
|
|
|
Service Code
|
HCPCS 80074
|
| Hospital Charge Code |
4300022
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$157.30 |
| Max. Negotiated Rate |
$157.30 |
| Rate for Payer: Cash Price |
$181.50
|
| Rate for Payer: Galaxy Health Commercial |
$157.30
|
|
|
ACUTE VENOUS THROMBOSIS IMAGE
|
Facility
|
IP
|
$4,063.00
|
|
|
Service Code
|
HCPCS 78456
|
| Hospital Charge Code |
4210002
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$2,640.95 |
| Max. Negotiated Rate |
$2,640.95 |
| Rate for Payer: Cash Price |
$3,047.25
|
| Rate for Payer: Galaxy Health Commercial |
$2,640.95
|
|
|
ACUTE VENOUS THROMBOSIS IMAGE
|
Facility
|
OP
|
$4,063.00
|
|
|
Service Code
|
HCPCS 78456
|
| Hospital Charge Code |
4210002
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$60.60 |
| Max. Negotiated Rate |
$3,270.72 |
| Rate for Payer: Aetna of NY Commercial |
$2,844.10
|
| Rate for Payer: Aetna of NY Medicare |
$1,868.98
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$3,047.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$3,047.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$1,503.31
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$2,031.50
|
| Rate for Payer: Cash Price |
$3,047.25
|
| Rate for Payer: Cash Price |
$3,047.25
|
| Rate for Payer: CDPHP Commercial |
$3,270.72
|
| Rate for Payer: CDPHP Medicare |
$1,503.31
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$2,844.10
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$3,250.40
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$3,250.40
|
| Rate for Payer: EmblemHealth Medicaid |
$3,250.40
|
| Rate for Payer: EmblemHealth Medicare |
$1,381.42
|
| Rate for Payer: EmblemHealth Select Care |
$2,640.95
|
| Rate for Payer: Fidelis Medicare |
$1,548.41
|
| Rate for Payer: Galaxy Health Commercial |
$2,640.95
|
| Rate for Payer: Hamaspik Choice Medicare |
$1,503.31
|
| Rate for Payer: Humana Medicare |
$1,503.31
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$2,844.10
|
| Rate for Payer: Local 1199SEIU Medicare |
$1,868.98
|
| Rate for Payer: MVP Health Care of NY Commercial |
$3,047.25
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$2,287.47
|
| Rate for Payer: MVP Health Care of NY Medicare |
$1,578.48
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$1,500.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$60.60
|
| Rate for Payer: United Healthcare Commercial |
$1,500.00
|
| Rate for Payer: United Healthcare Medicare |
$1,503.31
|
| Rate for Payer: WellCare Medicare |
$2,234.65
|
|
|
ACYCLOVIR 200 MG CAPSULE 200 mg, 100 eaches
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
NDC 00904578961
|
| Hospital Charge Code |
44001376
|
|
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
|
|
|
ACYCLOVIR 200 MG CAPSULE 200 mg, 100 eaches
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
NDC 00904578961
|
| Hospital Charge Code |
44001376
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.04 |
| Max. Negotiated Rate |
$4.83 |
| Rate for Payer: Aetna of NY Commercial |
$4.20
|
| Rate for Payer: Aetna of NY Medicare |
$2.76
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$4.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$4.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$2.22
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$3.00
|
| Rate for Payer: Cash Price |
$4.50
|
| Rate for Payer: CDPHP Commercial |
$4.83
|
| Rate for Payer: CDPHP Medicare |
$2.22
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$4.80
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$4.80
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$4.80
|
| Rate for Payer: EmblemHealth Medicaid |
$4.80
|
| Rate for Payer: EmblemHealth Medicare |
$2.04
|
| Rate for Payer: EmblemHealth Select Care |
$4.32
|
| Rate for Payer: Fidelis Medicare |
$2.29
|
| Rate for Payer: Galaxy Health Commercial |
$3.90
|
| Rate for Payer: Hamaspik Choice Medicare |
$2.22
|
| Rate for Payer: Humana Medicare |
$2.22
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$4.20
|
| Rate for Payer: Local 1199SEIU Medicare |
$2.76
|
| Rate for Payer: MVP Health Care of NY Commercial |
$4.50
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$3.38
|
| Rate for Payer: MVP Health Care of NY Medicare |
$2.33
|
| Rate for Payer: United Healthcare Medicare |
$2.22
|
| Rate for Payer: WellCare Medicare |
$3.30
|
|
|
ACYCLOVIR 400MG TABS 100 EA
|
Facility
|
IP
|
$11.59
|
|
|
Service Code
|
NDC 50268006115
|
| Hospital Charge Code |
4400016
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.37 |
| Max. Negotiated Rate |
$7.53 |
| Rate for Payer: Cash Price |
$8.69
|
| Rate for Payer: Galaxy Health Commercial |
$7.53
|
| Rate for Payer: WellCare Medicare |
$6.37
|
|
|
ACYCLOVIR 400MG TABS 100 EA
|
Facility
|
OP
|
$11.59
|
|
|
Service Code
|
NDC 50268006115
|
| Hospital Charge Code |
4400016
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.94 |
| Max. Negotiated Rate |
$9.33 |
| Rate for Payer: Aetna of NY Commercial |
$8.11
|
| Rate for Payer: Aetna of NY Medicare |
$5.33
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$8.69
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$8.69
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$4.29
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$5.80
|
| Rate for Payer: Cash Price |
$8.69
|
| Rate for Payer: CDPHP Commercial |
$9.33
|
| Rate for Payer: CDPHP Medicare |
$4.29
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$9.27
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$9.27
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$9.27
|
| Rate for Payer: EmblemHealth Medicaid |
$9.27
|
| Rate for Payer: EmblemHealth Medicare |
$3.94
|
| Rate for Payer: EmblemHealth Select Care |
$8.34
|
| Rate for Payer: Fidelis Medicare |
$4.42
|
| Rate for Payer: Galaxy Health Commercial |
$7.53
|
| Rate for Payer: Hamaspik Choice Medicare |
$4.29
|
| Rate for Payer: Humana Medicare |
$4.29
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$8.11
|
| Rate for Payer: Local 1199SEIU Medicare |
$5.33
|
| Rate for Payer: MVP Health Care of NY Commercial |
$8.69
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$6.53
|
| Rate for Payer: MVP Health Care of NY Medicare |
$4.50
|
| Rate for Payer: United Healthcare Medicare |
$4.29
|
| Rate for Payer: WellCare Medicare |
$6.37
|
|
|
ACYCLOVIR 5% OINTMENT 1 ea, 15 g
|
Facility
|
IP
|
$1,196.00
|
|
|
Service Code
|
NDC 65162083594
|
| Hospital Charge Code |
4401426
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$657.80 |
| Max. Negotiated Rate |
$777.40 |
| Rate for Payer: Cash Price |
$897.00
|
| Rate for Payer: Galaxy Health Commercial |
$777.40
|
| Rate for Payer: WellCare Medicare |
$657.80
|
|
|
ACYCLOVIR 5% OINTMENT 1 ea, 15 g
|
Facility
|
OP
|
$1,196.00
|
|
|
Service Code
|
NDC 65162083594
|
| Hospital Charge Code |
4401426
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$406.64 |
| Max. Negotiated Rate |
$962.78 |
| Rate for Payer: Aetna of NY Commercial |
$837.20
|
| Rate for Payer: Aetna of NY Medicare |
$550.16
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$897.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$897.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$442.52
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$598.00
|
| Rate for Payer: Cash Price |
$897.00
|
| Rate for Payer: CDPHP Commercial |
$962.78
|
| Rate for Payer: CDPHP Medicare |
$442.52
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$956.80
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$956.80
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$956.80
|
| Rate for Payer: EmblemHealth Medicaid |
$956.80
|
| Rate for Payer: EmblemHealth Medicare |
$406.64
|
| Rate for Payer: EmblemHealth Select Care |
$861.12
|
| Rate for Payer: Fidelis Medicare |
$455.80
|
| Rate for Payer: Galaxy Health Commercial |
$777.40
|
| Rate for Payer: Hamaspik Choice Medicare |
$442.52
|
| Rate for Payer: Humana Medicare |
$442.52
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$837.20
|
| Rate for Payer: Local 1199SEIU Medicare |
$550.16
|
| Rate for Payer: MVP Health Care of NY Commercial |
$897.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$673.35
|
| Rate for Payer: MVP Health Care of NY Medicare |
$464.65
|
| Rate for Payer: United Healthcare Medicare |
$442.52
|
| Rate for Payer: WellCare Medicare |
$657.80
|
|
|
ACYCLOVIR INJECTION 5 MG
|
Facility
|
IP
|
$69.78
|
|
|
Service Code
|
HCPCS J0133
|
| Hospital Charge Code |
4409180
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$45.36 |
| Rate for Payer: Aetna of NY Commercial |
$38.38
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$0.06
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$0.06
|
| Rate for Payer: Cash Price |
$52.34
|
| Rate for Payer: Cash Price |
$52.34
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$0.06
|
| Rate for Payer: EmblemHealth Select Care |
$0.06
|
| Rate for Payer: Galaxy Health Commercial |
$45.36
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$38.38
|
| Rate for Payer: WellCare Medicare |
$38.38
|
|
|
ACYCLOVIR INJECTION 5 MG
|
Facility
|
OP
|
$69.78
|
|
|
Service Code
|
HCPCS J0133
|
| Hospital Charge Code |
4409180
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$56.17 |
| Rate for Payer: Aetna of NY Commercial |
$38.38
|
| Rate for Payer: Aetna of NY Medicare |
$32.10
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$0.06
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$0.06
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$25.82
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$34.89
|
| Rate for Payer: Cash Price |
$52.34
|
| Rate for Payer: Cash Price |
$52.34
|
| Rate for Payer: CDPHP Commercial |
$56.17
|
| Rate for Payer: CDPHP Medicare |
$25.82
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$0.06
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$55.82
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$55.82
|
| Rate for Payer: EmblemHealth Medicaid |
$55.82
|
| Rate for Payer: EmblemHealth Medicare |
$23.73
|
| Rate for Payer: EmblemHealth Select Care |
$0.06
|
| Rate for Payer: Fidelis Medicare |
$26.59
|
| Rate for Payer: Galaxy Health Commercial |
$45.36
|
| Rate for Payer: Hamaspik Choice Medicare |
$25.82
|
| Rate for Payer: Humana Medicare |
$25.82
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$38.38
|
| Rate for Payer: Local 1199SEIU Medicare |
$32.10
|
| Rate for Payer: MVP Health Care of NY Commercial |
$52.34
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$39.29
|
| Rate for Payer: MVP Health Care of NY Medicare |
$27.11
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$0.08
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$0.06
|
| Rate for Payer: United Healthcare Commercial |
$0.08
|
| Rate for Payer: United Healthcare Medicare |
$25.82
|
| Rate for Payer: WellCare Medicare |
$38.38
|
|
|
ADAPTA DR
|
Facility
|
IP
|
$19,970.00
|
|
| Hospital Charge Code |
4471709
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,986.50 |
| Max. Negotiated Rate |
$13,979.00 |
| Rate for Payer: Aetna of NY Commercial |
$13,979.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$8,986.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$8,986.50
|
| Rate for Payer: Cash Price |
$14,977.50
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$9,985.00
|
| Rate for Payer: EmblemHealth Select Care |
$9,985.00
|
| Rate for Payer: Galaxy Health Commercial |
$12,980.50
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$13,979.00
|
| Rate for Payer: Multiplan Commercial |
$8,986.50
|
| Rate for Payer: MVP Health Care of NY Commercial |
$12,980.50
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$12,980.50
|
| Rate for Payer: WellCare Medicare |
$10,983.50
|
|
|
ADAPTA DR
|
Facility
|
OP
|
$19,970.00
|
|
| Hospital Charge Code |
4471709
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,789.80 |
| Max. Negotiated Rate |
$16,075.85 |
| Rate for Payer: Aetna of NY Commercial |
$13,979.00
|
| Rate for Payer: Aetna of NY Medicare |
$9,186.20
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$8,986.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$8,986.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$7,388.90
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$9,985.00
|
| Rate for Payer: Cash Price |
$14,977.50
|
| Rate for Payer: CDPHP Commercial |
$16,075.85
|
| Rate for Payer: CDPHP Medicare |
$7,388.90
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$9,985.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$15,976.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$15,976.00
|
| Rate for Payer: EmblemHealth Medicaid |
$15,976.00
|
| Rate for Payer: EmblemHealth Medicare |
$6,789.80
|
| Rate for Payer: EmblemHealth Select Care |
$9,985.00
|
| Rate for Payer: Fidelis Medicare |
$7,610.57
|
| Rate for Payer: Galaxy Health Commercial |
$12,980.50
|
| Rate for Payer: Hamaspik Choice Medicare |
$7,388.90
|
| Rate for Payer: Humana Medicare |
$7,388.90
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$13,979.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$9,186.20
|
| Rate for Payer: MVP Health Care of NY Commercial |
$12,980.50
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$12,980.50
|
| Rate for Payer: MVP Health Care of NY Medicare |
$7,758.34
|
| Rate for Payer: United Healthcare Medicare |
$7,388.90
|
| Rate for Payer: WellCare Medicare |
$10,983.50
|
|
|
ADDITIONAL IVP SAME DRUG INJ SEQ
|
Facility
|
OP
|
$192.00
|
|
|
Service Code
|
HCPCS 96376
|
| Hospital Charge Code |
4450109
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$9.66 |
| Max. Negotiated Rate |
$400.55 |
| Rate for Payer: Aetna of NY Commercial |
$134.40
|
| Rate for Payer: Aetna of NY Medicare |
$88.32
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$320.44
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$400.55
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$71.04
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$96.00
|
| Rate for Payer: Cash Price |
$144.00
|
| Rate for Payer: Cash Price |
$144.00
|
| Rate for Payer: Cash Price |
$144.00
|
| Rate for Payer: CDPHP Commercial |
$154.56
|
| Rate for Payer: CDPHP Medicare |
$71.04
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$153.60
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$153.60
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$153.60
|
| Rate for Payer: EmblemHealth Medicaid |
$153.60
|
| Rate for Payer: EmblemHealth Medicare |
$65.28
|
| Rate for Payer: EmblemHealth Select Care |
$138.24
|
| Rate for Payer: Fidelis Medicare |
$73.17
|
| Rate for Payer: Galaxy Health Commercial |
$124.80
|
| Rate for Payer: Hamaspik Choice Medicare |
$71.04
|
| Rate for Payer: Humana Medicare |
$71.04
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$134.40
|
| Rate for Payer: Local 1199SEIU Medicare |
$88.32
|
| Rate for Payer: MVP Health Care of NY Commercial |
$144.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$108.10
|
| Rate for Payer: MVP Health Care of NY Medicare |
$74.59
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$144.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$9.66
|
| Rate for Payer: United Healthcare Commercial |
$144.00
|
| Rate for Payer: United Healthcare Medicare |
$71.04
|
| Rate for Payer: WellCare Medicare |
$105.60
|
|
