|
ACETAMINOPHEN 325MG TABS 20X150EA
|
Facility
|
IP
|
$6.18
|
|
|
Service Code
|
NDC 904677361
|
| Hospital Charge Code |
4400783
|
|
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 325MG TABS 20X150EA
|
Facility
|
OP
|
$6.18
|
|
|
Service Code
|
NDC 904677361
|
| Hospital Charge Code |
4400783
|
|
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
|
|
|
ACETAZOLAMIDE 250MG TABS 100 EA
|
Facility
|
OP
|
$9.01
|
|
|
Service Code
|
NDC 51672402301
|
| Hospital Charge Code |
4400008
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.35 |
| Max. Negotiated Rate |
$7.21 |
| Rate for Payer: Aetna of NY Commercial |
$6.31
|
| Rate for Payer: Aetna of NY Medicare |
$4.14
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$3.60
|
| Rate for Payer: Cash Price |
$6.76
|
| Rate for Payer: CDPHP Medicare |
$3.33
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$7.21
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$7.21
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$7.21
|
| Rate for Payer: EmblemHealth Medicaid |
$7.21
|
| Rate for Payer: EmblemHealth Medicare |
$3.06
|
| Rate for Payer: EmblemHealth Select Care |
$6.49
|
| Rate for Payer: Fidelis Medicare |
$3.60
|
| Rate for Payer: Galaxy Health Commercial |
$5.86
|
| Rate for Payer: Hamaspik Choice Medicare |
$3.60
|
| Rate for Payer: Humana Medicare |
$3.60
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$6.31
|
| Rate for Payer: Local 1199SEIU Medicare |
$4.14
|
| Rate for Payer: MVP Health Care of NY Commercial |
$6.76
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$5.07
|
| Rate for Payer: MVP Health Care of NY Medicare |
$3.78
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$1.35
|
| Rate for Payer: United Healthcare Medicare |
$3.60
|
| Rate for Payer: WellCare Medicare |
$4.96
|
|
|
ACETAZOLAMIDE 250MG TABS 100 EA
|
Facility
|
IP
|
$9.01
|
|
|
Service Code
|
NDC 51672402301
|
| Hospital Charge Code |
4400008
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.96 |
| Max. Negotiated Rate |
$5.86 |
| Rate for Payer: Cash Price |
$6.76
|
| Rate for Payer: Galaxy Health Commercial |
$5.86
|
| Rate for Payer: WellCare Medicare |
$4.96
|
|
|
ACETYLCYSTEINE 200MG/ML AMPS 3X30ML
|
Facility
|
OP
|
$77.25
|
|
|
Service Code
|
NDC 409330803
|
| Hospital Charge Code |
4400011
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.59 |
| Max. Negotiated Rate |
$61.80 |
| Rate for Payer: Aetna of NY Commercial |
$54.08
|
| Rate for Payer: Aetna of NY Medicare |
$35.53
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$30.90
|
| Rate for Payer: Cash Price |
$57.94
|
| Rate for Payer: CDPHP Medicare |
$28.58
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$61.80
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$61.80
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$61.80
|
| Rate for Payer: EmblemHealth Medicaid |
$61.80
|
| Rate for Payer: EmblemHealth Medicare |
$26.27
|
| Rate for Payer: EmblemHealth Select Care |
$55.62
|
| Rate for Payer: Fidelis Medicare |
$30.90
|
| Rate for Payer: Galaxy Health Commercial |
$50.21
|
| Rate for Payer: Hamaspik Choice Medicare |
$30.90
|
| Rate for Payer: Humana Medicare |
$30.90
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$54.08
|
| Rate for Payer: Local 1199SEIU Medicare |
$35.53
|
| Rate for Payer: MVP Health Care of NY Commercial |
$57.94
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$43.49
|
| Rate for Payer: MVP Health Care of NY Medicare |
$32.45
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$11.59
|
| Rate for Payer: United Healthcare Medicare |
$30.90
|
| Rate for Payer: WellCare Medicare |
$42.49
|
|
|
ACETYLCYSTEINE 200MG/ML AMPS 3X30ML
|
Facility
|
IP
|
$77.25
|
|
|
Service Code
|
NDC 409330803
|
| Hospital Charge Code |
4400011
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$42.49 |
| Max. Negotiated Rate |
$50.21 |
| Rate for Payer: Cash Price |
$57.94
|
| Rate for Payer: Galaxy Health Commercial |
$50.21
|
| Rate for Payer: WellCare Medicare |
$42.49
|
|
|
ACETYLCYSTEINE 20% 4 ML
|
Facility
|
IP
|
$47.38
|
|
|
Service Code
|
NDC 63323069404
|
| Hospital Charge Code |
4401259
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.06 |
| Max. Negotiated Rate |
$30.80 |
| Rate for Payer: Cash Price |
$35.54
|
| Rate for Payer: Galaxy Health Commercial |
$30.80
|
| Rate for Payer: WellCare Medicare |
$26.06
|
|
|
ACETYLCYSTEINE 20% 4 ML
|
Facility
|
OP
|
$47.38
|
|
|
Service Code
|
NDC 63323069404
|
| Hospital Charge Code |
4401259
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.11 |
| Max. Negotiated Rate |
$37.90 |
| Rate for Payer: Aetna of NY Commercial |
$33.17
|
| Rate for Payer: Aetna of NY Medicare |
$21.79
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$18.95
|
| Rate for Payer: Cash Price |
$35.54
|
| Rate for Payer: CDPHP Medicare |
$17.53
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$37.90
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$37.90
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$37.90
|
| Rate for Payer: EmblemHealth Medicaid |
$37.90
|
| Rate for Payer: EmblemHealth Medicare |
$16.11
|
| Rate for Payer: EmblemHealth Select Care |
$34.11
|
| Rate for Payer: Fidelis Medicare |
$18.95
|
| Rate for Payer: Galaxy Health Commercial |
$30.80
|
| Rate for Payer: Hamaspik Choice Medicare |
$18.95
|
| Rate for Payer: Humana Medicare |
$18.95
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$33.17
|
| Rate for Payer: Local 1199SEIU Medicare |
$21.79
|
| Rate for Payer: MVP Health Care of NY Commercial |
$35.53
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$26.67
|
| Rate for Payer: MVP Health Care of NY Medicare |
$19.90
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$7.11
|
| Rate for Payer: United Healthcare Medicare |
$18.95
|
| Rate for Payer: WellCare Medicare |
$26.06
|
|
|
ACETYLCYSTEINE INJECTION 100 MG
|
Facility
|
IP
|
$10.50
|
|
|
Service Code
|
HCPCS J0132
|
| Hospital Charge Code |
4400004
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$6.83 |
| Rate for Payer: Aetna of NY Commercial |
$5.78
|
| Rate for Payer: Cash Price |
$7.88
|
| Rate for Payer: Cash Price |
$7.88
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$0.51
|
| Rate for Payer: EmblemHealth Select Care |
$0.51
|
| Rate for Payer: Galaxy Health Commercial |
$6.83
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$5.78
|
| Rate for Payer: WellCare Medicare |
$5.78
|
|
|
ACETYLCYSTEINE INJECTION 100 MG
|
Facility
|
OP
|
$10.50
|
|
|
Service Code
|
HCPCS J0132
|
| Hospital Charge Code |
4400004
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$8.40 |
| Rate for Payer: Aetna of NY Medicare |
$4.83
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$4.20
|
| Rate for Payer: Cash Price |
$7.88
|
| Rate for Payer: Cash Price |
$7.88
|
| Rate for Payer: CDPHP Medicare |
$3.88
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$0.51
|
| 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 |
$0.51
|
| Rate for Payer: Fidelis Medicare |
$4.20
|
| Rate for Payer: Galaxy Health Commercial |
$6.83
|
| Rate for Payer: Hamaspik Choice Medicare |
$4.20
|
| Rate for Payer: Humana Medicare |
$4.20
|
| 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 |
$4.41
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$1.29
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$1.57
|
| Rate for Payer: United Healthcare Commercial |
$1.29
|
| Rate for Payer: United Healthcare Medicare |
$4.20
|
| Rate for Payer: WellCare Medicare |
$5.78
|
|
|
ACID FAST SMEAR
|
Facility
|
OP
|
$16.00
|
|
|
Service Code
|
HCPCS 87206
|
| Hospital Charge Code |
4300019
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$2.40 |
| Max. Negotiated Rate |
$12.80 |
| Rate for Payer: Aetna of NY Commercial |
$10.40
|
| Rate for Payer: Aetna of NY Medicare |
$7.36
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$6.40
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: CDPHP Medicare |
$5.92
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$9.60
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$12.80
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$12.80
|
| Rate for Payer: EmblemHealth Medicaid |
$12.80
|
| Rate for Payer: EmblemHealth Medicare |
$5.44
|
| Rate for Payer: EmblemHealth Select Care |
$9.60
|
| Rate for Payer: Fidelis Medicare |
$6.40
|
| Rate for Payer: Galaxy Health Commercial |
$10.40
|
| Rate for Payer: Hamaspik Choice Medicare |
$6.40
|
| Rate for Payer: Humana Medicare |
$6.40
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$10.40
|
| Rate for Payer: Local 1199SEIU Medicare |
$7.36
|
| Rate for Payer: MVP Health Care of NY Commercial |
$12.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$9.01
|
| Rate for Payer: MVP Health Care of NY Medicare |
$6.72
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$12.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$2.40
|
| Rate for Payer: United Healthcare Commercial |
$12.00
|
| Rate for Payer: United Healthcare Medicare |
$6.40
|
| Rate for Payer: WellCare Medicare |
$8.80
|
|
|
ACID FAST SMEAR
|
Facility
|
IP
|
$16.00
|
|
|
Service Code
|
HCPCS 87206
|
| Hospital Charge Code |
4300019
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$10.40 |
| Max. Negotiated Rate |
$10.40 |
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Galaxy Health Commercial |
$10.40
|
|
|
ACTH
|
Facility
|
IP
|
$116.00
|
|
|
Service Code
|
HCPCS 82024
|
| Hospital Charge Code |
4300021
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$75.40 |
| Max. Negotiated Rate |
$75.40 |
| Rate for Payer: Cash Price |
$87.00
|
| Rate for Payer: Galaxy Health Commercial |
$75.40
|
|
|
ACTH
|
Facility
|
OP
|
$116.00
|
|
|
Service Code
|
HCPCS 82024
|
| Hospital Charge Code |
4300021
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$17.40 |
| Max. Negotiated Rate |
$92.80 |
| Rate for Payer: Aetna of NY Commercial |
$75.40
|
| Rate for Payer: Aetna of NY Medicare |
$53.36
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$46.40
|
| Rate for Payer: Cash Price |
$87.00
|
| Rate for Payer: CDPHP Medicare |
$42.92
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$69.60
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$92.80
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$92.80
|
| Rate for Payer: EmblemHealth Medicaid |
$92.80
|
| Rate for Payer: EmblemHealth Medicare |
$39.44
|
| Rate for Payer: EmblemHealth Select Care |
$69.60
|
| Rate for Payer: Fidelis Medicare |
$46.40
|
| Rate for Payer: Galaxy Health Commercial |
$75.40
|
| Rate for Payer: Hamaspik Choice Medicare |
$46.40
|
| Rate for Payer: Humana Medicare |
$46.40
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$75.40
|
| Rate for Payer: Local 1199SEIU Medicare |
$53.36
|
| Rate for Payer: MVP Health Care of NY Commercial |
$87.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$65.31
|
| Rate for Payer: MVP Health Care of NY Medicare |
$48.72
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$87.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$17.40
|
| Rate for Payer: United Healthcare Commercial |
$87.00
|
| Rate for Payer: United Healthcare Medicare |
$46.40
|
| Rate for Payer: WellCare Medicare |
$63.80
|
|
|
ACTIVATED CHARCOAL 50GM LIQD 240 ML
|
Facility
|
IP
|
$73.13
|
|
|
Service Code
|
NDC 574012176
|
| 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 574012176
|
| Hospital Charge Code |
4400015
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.97 |
| Max. Negotiated Rate |
$58.50 |
| 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) Medicare |
$29.25
|
| Rate for Payer: Cash Price |
$54.85
|
| 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 |
$29.25
|
| Rate for Payer: Galaxy Health Commercial |
$47.53
|
| Rate for Payer: Hamaspik Choice Medicare |
$29.25
|
| Rate for Payer: Humana Medicare |
$29.25
|
| 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 |
$30.71
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$10.97
|
| Rate for Payer: United Healthcare Medicare |
$29.25
|
| Rate for Payer: WellCare Medicare |
$40.22
|
|
|
ACTOS 15 MG
|
Facility
|
OP
|
$21.05
|
|
|
Service Code
|
NDC 781542092
|
| Hospital Charge Code |
4409012
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.16 |
| Max. Negotiated Rate |
$16.84 |
| Rate for Payer: Aetna of NY Commercial |
$14.73
|
| Rate for Payer: Aetna of NY Medicare |
$9.68
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$8.42
|
| Rate for Payer: Cash Price |
$15.79
|
| 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 |
$8.42
|
| Rate for Payer: Galaxy Health Commercial |
$13.68
|
| Rate for Payer: Hamaspik Choice Medicare |
$8.42
|
| Rate for Payer: Humana Medicare |
$8.42
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$14.73
|
| 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 |
$8.84
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$3.16
|
| Rate for Payer: United Healthcare Medicare |
$8.42
|
| Rate for Payer: WellCare Medicare |
$11.58
|
|
|
ACTOS 15 MG
|
Facility
|
IP
|
$21.05
|
|
|
Service Code
|
NDC 781542092
|
| 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 |
$36.30 |
| Max. Negotiated Rate |
$193.60 |
| 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) Medicare |
$96.80
|
| Rate for Payer: Cash Price |
$181.50
|
| 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 |
$96.80
|
| Rate for Payer: Galaxy Health Commercial |
$157.30
|
| Rate for Payer: Hamaspik Choice Medicare |
$96.80
|
| Rate for Payer: Humana Medicare |
$96.80
|
| 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 |
$101.64
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$181.50
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$36.30
|
| Rate for Payer: United Healthcare Commercial |
$181.50
|
| Rate for Payer: United Healthcare Medicare |
$96.80
|
| 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
|
$143.00
|
|
|
Service Code
|
HCPCS 78456 26
|
| Hospital Charge Code |
5210002
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$21.45 |
| Max. Negotiated Rate |
$114.40 |
| Rate for Payer: Aetna of NY Commercial |
$100.10
|
| Rate for Payer: Aetna of NY Medicare |
$65.78
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$57.20
|
| Rate for Payer: Cash Price |
$107.25
|
| Rate for Payer: CDPHP Medicare |
$52.91
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$114.40
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$114.40
|
| Rate for Payer: EmblemHealth Medicaid |
$114.40
|
| Rate for Payer: EmblemHealth Medicare |
$48.62
|
| Rate for Payer: Fidelis Medicare |
$57.20
|
| Rate for Payer: Galaxy Health Commercial |
$92.95
|
| Rate for Payer: Hamaspik Choice Medicare |
$57.20
|
| Rate for Payer: Humana Medicare |
$57.20
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$100.10
|
| Rate for Payer: Local 1199SEIU Medicare |
$65.78
|
| Rate for Payer: MVP Health Care of NY Commercial |
$107.25
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$80.51
|
| Rate for Payer: MVP Health Care of NY Medicare |
$60.06
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$21.45
|
| Rate for Payer: United Healthcare Medicare |
$57.20
|
| Rate for Payer: WellCare Medicare |
$78.65
|
|
|
ACUTE VENOUS THROMBOSIS IMAGE
|
Facility
|
IP
|
$143.00
|
|
|
Service Code
|
HCPCS 78456 26
|
| Hospital Charge Code |
5210002
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$92.95 |
| Max. Negotiated Rate |
$92.95 |
| Rate for Payer: Cash Price |
$107.25
|
| Rate for Payer: Galaxy Health Commercial |
$92.95
|
|
|
ACUTE VENOUS THROMBOSIS IMAGE
|
Facility
|
OP
|
$4,063.00
|
|
|
Service Code
|
HCPCS 78456
|
| Hospital Charge Code |
4210002
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$609.45 |
| Max. Negotiated Rate |
$3,250.40 |
| 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) Medicare |
$1,625.20
|
| Rate for Payer: Cash Price |
$3,047.25
|
| Rate for Payer: Cash Price |
$3,047.25
|
| 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 |
$1,625.20
|
| Rate for Payer: Galaxy Health Commercial |
$2,640.95
|
| Rate for Payer: Hamaspik Choice Medicare |
$1,625.20
|
| Rate for Payer: Humana Medicare |
$1,625.20
|
| 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 |
$1,706.46
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$1,545.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$609.45
|
| Rate for Payer: United Healthcare Commercial |
$1,545.00
|
| Rate for Payer: United Healthcare Medicare |
$1,625.20
|
| Rate for Payer: WellCare Medicare |
$2,234.65
|
|
|
ACYCLOVIR 200 MG CAPSULE 200 mg, 100 eaches
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
NDC 904578961
|
| Hospital Charge Code |
44001376
|
|
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
|
|
