|
NORTRIPTYLINE 25 MG CAPSULE
|
Facility
|
IP
|
$6.18
|
|
|
Service Code
|
NDC 00093081101
|
| Hospital Charge Code |
4409090
|
|
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
|
|
|
NORTRIPTYLINE 25 MG CAPSULE
|
Facility
|
OP
|
$6.18
|
|
|
Service Code
|
NDC 00093081101
|
| Hospital Charge Code |
4409090
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.10 |
| Max. Negotiated Rate |
$4.97 |
| 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) Blue Access/Small Group |
$4.64
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$4.64
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$2.29
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$3.09
|
| Rate for Payer: Cash Price |
$4.64
|
| Rate for Payer: CDPHP Commercial |
$4.97
|
| 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 |
$2.36
|
| Rate for Payer: Galaxy Health Commercial |
$4.02
|
| Rate for Payer: Hamaspik Choice Medicare |
$2.29
|
| Rate for Payer: Humana Medicare |
$2.29
|
| 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 |
$4.64
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$3.48
|
| Rate for Payer: MVP Health Care of NY Medicare |
$2.40
|
| Rate for Payer: United Healthcare Medicare |
$2.29
|
| Rate for Payer: WellCare Medicare |
$3.40
|
|
|
NORTRIPTYLINE HCL 10 MG CAP 10 mg, 100 eaches
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
NDC 51672400101
|
| Hospital Charge Code |
4401513
|
|
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
|
|
|
NORTRIPTYLINE HCL 10 MG CAP 10 mg, 100 eaches
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
NDC 51672400101
|
| Hospital Charge Code |
4401513
|
|
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
|
|
|
NovoLIN N 100 UNIT/ML FLEXPEN 3 mL, 3 mL
|
Facility
|
IP
|
$188.00
|
|
|
Service Code
|
NDC 00169300415
|
| Hospital Charge Code |
4401537
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$103.40 |
| Max. Negotiated Rate |
$122.20 |
| Rate for Payer: Cash Price |
$141.00
|
| Rate for Payer: Galaxy Health Commercial |
$122.20
|
| Rate for Payer: WellCare Medicare |
$103.40
|
|
|
NovoLIN N 100 UNIT/ML FLEXPEN 3 mL, 3 mL
|
Facility
|
OP
|
$188.00
|
|
|
Service Code
|
NDC 00169300415
|
| Hospital Charge Code |
4401537
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$63.92 |
| Max. Negotiated Rate |
$151.34 |
| Rate for Payer: Aetna of NY Commercial |
$131.60
|
| Rate for Payer: Aetna of NY Medicare |
$86.48
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$141.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$141.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$69.56
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$94.00
|
| Rate for Payer: Cash Price |
$141.00
|
| Rate for Payer: CDPHP Commercial |
$151.34
|
| Rate for Payer: CDPHP Medicare |
$69.56
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$150.40
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$150.40
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$150.40
|
| Rate for Payer: EmblemHealth Medicaid |
$150.40
|
| Rate for Payer: EmblemHealth Medicare |
$63.92
|
| Rate for Payer: EmblemHealth Select Care |
$135.36
|
| Rate for Payer: Fidelis Medicare |
$71.65
|
| Rate for Payer: Galaxy Health Commercial |
$122.20
|
| Rate for Payer: Hamaspik Choice Medicare |
$69.56
|
| Rate for Payer: Humana Medicare |
$69.56
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$131.60
|
| Rate for Payer: Local 1199SEIU Medicare |
$86.48
|
| Rate for Payer: MVP Health Care of NY Commercial |
$141.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$105.84
|
| Rate for Payer: MVP Health Care of NY Medicare |
$73.04
|
| Rate for Payer: United Healthcare Medicare |
$69.56
|
| Rate for Payer: WellCare Medicare |
$103.40
|
|
|
NULOJIX 250 MG VIAL 1 mg, 1 each
|
Facility
|
IP
|
$14.00
|
|
|
Service Code
|
HCPCS J0485
|
| Hospital Charge Code |
4401410
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.87 |
| Max. Negotiated Rate |
$9.10 |
| Rate for Payer: Aetna of NY Commercial |
$7.70
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$3.87
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$3.87
|
| Rate for Payer: Cash Price |
$10.50
|
| Rate for Payer: Cash Price |
$10.50
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$3.87
|
| Rate for Payer: EmblemHealth Select Care |
$3.87
|
| Rate for Payer: Galaxy Health Commercial |
$9.10
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$7.70
|
| Rate for Payer: WellCare Medicare |
$7.70
|
|
|
NULOJIX 250 MG VIAL 1 mg, 1 each
|
Facility
|
OP
|
$14.00
|
|
|
Service Code
|
HCPCS J0485
|
| Hospital Charge Code |
4401410
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.87 |
| Max. Negotiated Rate |
$11.27 |
| Rate for Payer: Aetna of NY Commercial |
$7.70
|
| Rate for Payer: Aetna of NY Medicare |
$6.44
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$3.87
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$3.87
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$5.18
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$7.00
|
| Rate for Payer: Cash Price |
$10.50
|
| Rate for Payer: Cash Price |
$10.50
|
| Rate for Payer: CDPHP Commercial |
$11.27
|
| Rate for Payer: CDPHP Medicare |
$5.18
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$3.87
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$11.20
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$11.20
|
| Rate for Payer: EmblemHealth Medicaid |
$11.20
|
| Rate for Payer: EmblemHealth Medicare |
$4.76
|
| Rate for Payer: EmblemHealth Select Care |
$3.87
|
| Rate for Payer: Fidelis Medicare |
$5.34
|
| Rate for Payer: Galaxy Health Commercial |
$9.10
|
| Rate for Payer: Hamaspik Choice Medicare |
$5.18
|
| Rate for Payer: Humana Medicare |
$5.18
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$7.70
|
| Rate for Payer: Local 1199SEIU Medicare |
$6.44
|
| Rate for Payer: MVP Health Care of NY Commercial |
$10.50
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$7.88
|
| Rate for Payer: MVP Health Care of NY Medicare |
$5.44
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$6.24
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$3.87
|
| Rate for Payer: United Healthcare Commercial |
$6.24
|
| Rate for Payer: United Healthcare Medicare |
$5.18
|
| Rate for Payer: WellCare Medicare |
$7.70
|
|
|
NYAMYC 100,000 UNIT/GM POWDER 100000 g, 60 g
|
Facility
|
IP
|
$392.00
|
|
|
Service Code
|
NDC 00832046560
|
| Hospital Charge Code |
4401562
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$215.60 |
| Max. Negotiated Rate |
$254.80 |
| Rate for Payer: Cash Price |
$294.00
|
| Rate for Payer: Galaxy Health Commercial |
$254.80
|
| Rate for Payer: WellCare Medicare |
$215.60
|
|
|
NYAMYC 100,000 UNIT/GM POWDER 100000 g, 60 g
|
Facility
|
OP
|
$392.00
|
|
|
Service Code
|
NDC 00832046560
|
| Hospital Charge Code |
4401562
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$133.28 |
| Max. Negotiated Rate |
$315.56 |
| Rate for Payer: Aetna of NY Commercial |
$274.40
|
| Rate for Payer: Aetna of NY Medicare |
$180.32
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$294.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$294.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$145.04
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$196.00
|
| Rate for Payer: Cash Price |
$294.00
|
| Rate for Payer: CDPHP Commercial |
$315.56
|
| Rate for Payer: CDPHP Medicare |
$145.04
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$313.60
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$313.60
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$313.60
|
| Rate for Payer: EmblemHealth Medicaid |
$313.60
|
| Rate for Payer: EmblemHealth Medicare |
$133.28
|
| Rate for Payer: EmblemHealth Select Care |
$282.24
|
| Rate for Payer: Fidelis Medicare |
$149.39
|
| Rate for Payer: Galaxy Health Commercial |
$254.80
|
| Rate for Payer: Hamaspik Choice Medicare |
$145.04
|
| Rate for Payer: Humana Medicare |
$145.04
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$274.40
|
| Rate for Payer: Local 1199SEIU Medicare |
$180.32
|
| Rate for Payer: MVP Health Care of NY Commercial |
$294.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$220.70
|
| Rate for Payer: MVP Health Care of NY Medicare |
$152.29
|
| Rate for Payer: United Healthcare Medicare |
$145.04
|
| Rate for Payer: WellCare Medicare |
$215.60
|
|
|
NYSATIN ORAL SUP 5ML
|
Facility
|
IP
|
$6.18
|
|
|
Service Code
|
NDC 66689003701
|
| Hospital Charge Code |
4409176
|
|
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
|
|
|
NYSATIN ORAL SUP 5ML
|
Facility
|
OP
|
$6.18
|
|
|
Service Code
|
NDC 66689003701
|
| Hospital Charge Code |
4409176
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.10 |
| Max. Negotiated Rate |
$4.97 |
| 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) Blue Access/Small Group |
$4.64
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$4.64
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$2.29
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$3.09
|
| Rate for Payer: Cash Price |
$4.64
|
| Rate for Payer: CDPHP Commercial |
$4.97
|
| 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 |
$2.36
|
| Rate for Payer: Galaxy Health Commercial |
$4.02
|
| Rate for Payer: Hamaspik Choice Medicare |
$2.29
|
| Rate for Payer: Humana Medicare |
$2.29
|
| 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 |
$4.64
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$3.48
|
| Rate for Payer: MVP Health Care of NY Medicare |
$2.40
|
| Rate for Payer: United Healthcare Medicare |
$2.29
|
| Rate for Payer: WellCare Medicare |
$3.40
|
|
|
NYSTATIN 100MU/GM CRM 30 GM
|
Facility
|
IP
|
$81.11
|
|
|
Service Code
|
NDC 45802005911
|
| Hospital Charge Code |
4400580
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$44.61 |
| Max. Negotiated Rate |
$52.72 |
| Rate for Payer: Cash Price |
$60.83
|
| Rate for Payer: Galaxy Health Commercial |
$52.72
|
| Rate for Payer: WellCare Medicare |
$44.61
|
|
|
NYSTATIN 100MU/GM CRM 30 GM
|
Facility
|
OP
|
$81.11
|
|
|
Service Code
|
NDC 45802005911
|
| Hospital Charge Code |
4400580
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$27.58 |
| Max. Negotiated Rate |
$65.29 |
| Rate for Payer: Aetna of NY Commercial |
$56.78
|
| Rate for Payer: Aetna of NY Medicare |
$37.31
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$60.83
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$60.83
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$30.01
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$40.56
|
| Rate for Payer: Cash Price |
$60.83
|
| Rate for Payer: CDPHP Commercial |
$65.29
|
| Rate for Payer: CDPHP Medicare |
$30.01
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$64.89
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$64.89
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$64.89
|
| Rate for Payer: EmblemHealth Medicaid |
$64.89
|
| Rate for Payer: EmblemHealth Medicare |
$27.58
|
| Rate for Payer: EmblemHealth Select Care |
$58.40
|
| Rate for Payer: Fidelis Medicare |
$30.91
|
| Rate for Payer: Galaxy Health Commercial |
$52.72
|
| Rate for Payer: Hamaspik Choice Medicare |
$30.01
|
| Rate for Payer: Humana Medicare |
$30.01
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$56.78
|
| Rate for Payer: Local 1199SEIU Medicare |
$37.31
|
| Rate for Payer: MVP Health Care of NY Commercial |
$60.83
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$45.66
|
| Rate for Payer: MVP Health Care of NY Medicare |
$31.51
|
| Rate for Payer: United Healthcare Medicare |
$30.01
|
| Rate for Payer: WellCare Medicare |
$44.61
|
|
|
NYSTATIN 100MU/GM POWD 15 GM
|
Facility
|
OP
|
$115.62
|
|
|
Service Code
|
NDC 00832046515
|
| Hospital Charge Code |
4400578
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$39.31 |
| Max. Negotiated Rate |
$93.07 |
| Rate for Payer: Aetna of NY Commercial |
$80.93
|
| Rate for Payer: Aetna of NY Medicare |
$53.19
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$86.72
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$86.72
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$42.78
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$57.81
|
| Rate for Payer: Cash Price |
$86.72
|
| Rate for Payer: CDPHP Commercial |
$93.07
|
| Rate for Payer: CDPHP Medicare |
$42.78
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$92.50
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$92.50
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$92.50
|
| Rate for Payer: EmblemHealth Medicaid |
$92.50
|
| Rate for Payer: EmblemHealth Medicare |
$39.31
|
| Rate for Payer: EmblemHealth Select Care |
$83.25
|
| Rate for Payer: Fidelis Medicare |
$44.06
|
| Rate for Payer: Galaxy Health Commercial |
$75.15
|
| Rate for Payer: Hamaspik Choice Medicare |
$42.78
|
| Rate for Payer: Humana Medicare |
$42.78
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$80.93
|
| Rate for Payer: Local 1199SEIU Medicare |
$53.19
|
| Rate for Payer: MVP Health Care of NY Commercial |
$86.72
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$65.09
|
| Rate for Payer: MVP Health Care of NY Medicare |
$44.92
|
| Rate for Payer: United Healthcare Medicare |
$42.78
|
| Rate for Payer: WellCare Medicare |
$63.59
|
|
|
NYSTATIN 100MU/GM POWD 15 GM
|
Facility
|
IP
|
$115.62
|
|
|
Service Code
|
NDC 00832046515
|
| Hospital Charge Code |
4400578
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$63.59 |
| Max. Negotiated Rate |
$75.15 |
| Rate for Payer: Cash Price |
$86.72
|
| Rate for Payer: Galaxy Health Commercial |
$75.15
|
| Rate for Payer: WellCare Medicare |
$63.59
|
|
|
NYSTATIN OINTMENT 30 GRAMS
|
Facility
|
OP
|
$77.77
|
|
|
Service Code
|
NDC 00168000730
|
| Hospital Charge Code |
4409149
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.44 |
| Max. Negotiated Rate |
$62.60 |
| Rate for Payer: Aetna of NY Commercial |
$54.44
|
| Rate for Payer: Aetna of NY Medicare |
$35.77
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$58.33
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$58.33
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$28.77
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$38.88
|
| Rate for Payer: Cash Price |
$58.33
|
| Rate for Payer: CDPHP Commercial |
$62.60
|
| Rate for Payer: CDPHP Medicare |
$28.77
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$62.22
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$62.22
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$62.22
|
| Rate for Payer: EmblemHealth Medicaid |
$62.22
|
| Rate for Payer: EmblemHealth Medicare |
$26.44
|
| Rate for Payer: EmblemHealth Select Care |
$55.99
|
| Rate for Payer: Fidelis Medicare |
$29.64
|
| Rate for Payer: Galaxy Health Commercial |
$50.55
|
| Rate for Payer: Hamaspik Choice Medicare |
$28.77
|
| Rate for Payer: Humana Medicare |
$28.77
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$54.44
|
| Rate for Payer: Local 1199SEIU Medicare |
$35.77
|
| Rate for Payer: MVP Health Care of NY Commercial |
$58.33
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$43.78
|
| Rate for Payer: MVP Health Care of NY Medicare |
$30.21
|
| Rate for Payer: United Healthcare Medicare |
$28.77
|
| Rate for Payer: WellCare Medicare |
$42.77
|
|
|
NYSTATIN OINTMENT 30 GRAMS
|
Facility
|
IP
|
$77.77
|
|
|
Service Code
|
NDC 00168000730
|
| Hospital Charge Code |
4409149
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$42.77 |
| Max. Negotiated Rate |
$50.55 |
| Rate for Payer: Cash Price |
$58.33
|
| Rate for Payer: Galaxy Health Commercial |
$50.55
|
| Rate for Payer: WellCare Medicare |
$42.77
|
|
|
NYSTATIN POWDER 30 GRAMS
|
Facility
|
OP
|
$226.60
|
|
|
Service Code
|
NDC 00832046530
|
| Hospital Charge Code |
4409148
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$77.04 |
| Max. Negotiated Rate |
$182.41 |
| Rate for Payer: Aetna of NY Commercial |
$158.62
|
| Rate for Payer: Aetna of NY Medicare |
$104.24
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$169.95
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$169.95
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$83.84
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$113.30
|
| Rate for Payer: Cash Price |
$169.95
|
| Rate for Payer: CDPHP Commercial |
$182.41
|
| Rate for Payer: CDPHP Medicare |
$83.84
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$181.28
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$181.28
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$181.28
|
| Rate for Payer: EmblemHealth Medicaid |
$181.28
|
| Rate for Payer: EmblemHealth Medicare |
$77.04
|
| Rate for Payer: EmblemHealth Select Care |
$163.15
|
| Rate for Payer: Fidelis Medicare |
$86.36
|
| Rate for Payer: Galaxy Health Commercial |
$147.29
|
| Rate for Payer: Hamaspik Choice Medicare |
$83.84
|
| Rate for Payer: Humana Medicare |
$83.84
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$158.62
|
| Rate for Payer: Local 1199SEIU Medicare |
$104.24
|
| Rate for Payer: MVP Health Care of NY Commercial |
$169.95
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$127.58
|
| Rate for Payer: MVP Health Care of NY Medicare |
$88.03
|
| Rate for Payer: United Healthcare Medicare |
$83.84
|
| Rate for Payer: WellCare Medicare |
$124.63
|
|
|
NYSTATIN POWDER 30 GRAMS
|
Facility
|
IP
|
$226.60
|
|
|
Service Code
|
NDC 00832046530
|
| Hospital Charge Code |
4409148
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$124.63 |
| Max. Negotiated Rate |
$147.29 |
| Rate for Payer: Cash Price |
$169.95
|
| Rate for Payer: Galaxy Health Commercial |
$147.29
|
| Rate for Payer: WellCare Medicare |
$124.63
|
|
|
NYSTATIN/TRIAMCINOLONE 100MU-0.1%/GM CRM
|
Facility
|
OP
|
$345.82
|
|
|
Service Code
|
NDC 51672126301
|
| Hospital Charge Code |
4400582
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$117.58 |
| Max. Negotiated Rate |
$278.39 |
| Rate for Payer: Aetna of NY Commercial |
$242.07
|
| Rate for Payer: Aetna of NY Medicare |
$159.08
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$259.36
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$259.36
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$127.95
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$172.91
|
| Rate for Payer: Cash Price |
$259.37
|
| Rate for Payer: CDPHP Commercial |
$278.39
|
| Rate for Payer: CDPHP Medicare |
$127.95
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$276.66
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$276.66
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$276.66
|
| Rate for Payer: EmblemHealth Medicaid |
$276.66
|
| Rate for Payer: EmblemHealth Medicare |
$117.58
|
| Rate for Payer: EmblemHealth Select Care |
$248.99
|
| Rate for Payer: Fidelis Medicare |
$131.79
|
| Rate for Payer: Galaxy Health Commercial |
$224.78
|
| Rate for Payer: Hamaspik Choice Medicare |
$127.95
|
| Rate for Payer: Humana Medicare |
$127.95
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$242.07
|
| Rate for Payer: Local 1199SEIU Medicare |
$159.08
|
| Rate for Payer: MVP Health Care of NY Commercial |
$259.36
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$194.70
|
| Rate for Payer: MVP Health Care of NY Medicare |
$134.35
|
| Rate for Payer: United Healthcare Medicare |
$127.95
|
| Rate for Payer: WellCare Medicare |
$190.20
|
|
|
NYSTATIN/TRIAMCINOLONE 100MU-0.1%/GM CRM
|
Facility
|
IP
|
$345.82
|
|
|
Service Code
|
NDC 51672126301
|
| Hospital Charge Code |
4400582
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$190.20 |
| Max. Negotiated Rate |
$224.78 |
| Rate for Payer: Cash Price |
$259.37
|
| Rate for Payer: Galaxy Health Commercial |
$224.78
|
| Rate for Payer: WellCare Medicare |
$190.20
|
|
|
O2 SENSOR ADULT
|
Facility
|
IP
|
$32.00
|
|
| Hospital Charge Code |
4479162
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$20.80 |
| Max. Negotiated Rate |
$20.80 |
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: Galaxy Health Commercial |
$20.80
|
|
|
O2 SENSOR ADULT
|
Facility
|
OP
|
$32.00
|
|
| Hospital Charge Code |
4479162
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$10.88 |
| Max. Negotiated Rate |
$25.76 |
| Rate for Payer: Aetna of NY Commercial |
$22.40
|
| Rate for Payer: Aetna of NY Medicare |
$14.72
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$24.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$24.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$11.84
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$16.00
|
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: CDPHP Commercial |
$25.76
|
| Rate for Payer: CDPHP Medicare |
$11.84
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$25.60
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$25.60
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$25.60
|
| Rate for Payer: EmblemHealth Medicaid |
$25.60
|
| Rate for Payer: EmblemHealth Medicare |
$10.88
|
| Rate for Payer: EmblemHealth Select Care |
$23.04
|
| Rate for Payer: Fidelis Medicare |
$12.20
|
| Rate for Payer: Galaxy Health Commercial |
$20.80
|
| Rate for Payer: Hamaspik Choice Medicare |
$11.84
|
| Rate for Payer: Humana Medicare |
$11.84
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$22.40
|
| Rate for Payer: Local 1199SEIU Medicare |
$14.72
|
| Rate for Payer: MVP Health Care of NY Commercial |
$24.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$18.02
|
| Rate for Payer: MVP Health Care of NY Medicare |
$12.43
|
| Rate for Payer: United Healthcare Medicare |
$11.84
|
| Rate for Payer: WellCare Medicare |
$17.60
|
|
|
OBSERVATION ROOM 1 HR-EMER RM
|
Facility
|
OP
|
$142.00
|
|
|
Service Code
|
HCPCS G0378
|
| Hospital Charge Code |
4760002
|
|
Hospital Revenue Code
|
762
|
| Min. Negotiated Rate |
$48.28 |
| Max. Negotiated Rate |
$4,175.13 |
| Rate for Payer: Aetna of NY Commercial |
$3,629.00
|
| Rate for Payer: Aetna of NY Medicare |
$65.32
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$3,339.68
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$4,175.13
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$52.54
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$2,255.00
|
| Rate for Payer: Cash Price |
$106.50
|
| Rate for Payer: Cash Price |
$106.50
|
| Rate for Payer: Cash Price |
$106.50
|
| Rate for Payer: CDPHP Commercial |
$114.31
|
| Rate for Payer: CDPHP Medicare |
$52.54
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$2,700.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$113.60
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$113.60
|
| Rate for Payer: EmblemHealth Medicaid |
$113.60
|
| Rate for Payer: EmblemHealth Medicare |
$48.28
|
| Rate for Payer: EmblemHealth Select Care |
$2,430.00
|
| Rate for Payer: Fidelis Child Health Plus/Essential Plan/HARP/Medicaid |
$1,825.00
|
| Rate for Payer: Fidelis Medicare |
$54.12
|
| Rate for Payer: Galaxy Health Commercial |
$92.30
|
| Rate for Payer: Hamaspik Choice Medicare |
$52.54
|
| Rate for Payer: Humana Medicare |
$52.54
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$3,629.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$65.32
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,652.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$1,989.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$55.17
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$3,134.00
|
| Rate for Payer: United Healthcare Commercial |
$3,134.00
|
| Rate for Payer: United Healthcare Medicare |
$52.54
|
| Rate for Payer: WellCare Medicare |
$78.10
|
|
