|
OXYCODONE HCL 20MG TABS 2X10EA
|
Facility
|
IP
|
$21.63
|
|
|
Service Code
|
NDC 59011042020
|
| Hospital Charge Code |
4400603
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.90 |
| Max. Negotiated Rate |
$14.06 |
| Rate for Payer: Cash Price |
$16.22
|
| Rate for Payer: Galaxy Health Commercial |
$14.06
|
| Rate for Payer: WellCare Medicare |
$11.90
|
|
|
OXYCODONE HCL 20MG TABS 2X10EA
|
Facility
|
OP
|
$21.63
|
|
|
Service Code
|
NDC 59011042020
|
| Hospital Charge Code |
4400603
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.35 |
| Max. Negotiated Rate |
$17.41 |
| Rate for Payer: Aetna of NY Commercial |
$15.14
|
| Rate for Payer: Aetna of NY Medicare |
$9.95
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$16.22
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$16.22
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$8.00
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$10.82
|
| Rate for Payer: Cash Price |
$16.22
|
| Rate for Payer: CDPHP Commercial |
$17.41
|
| Rate for Payer: CDPHP Medicare |
$8.00
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$17.30
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$17.30
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$17.30
|
| Rate for Payer: EmblemHealth Medicaid |
$17.30
|
| Rate for Payer: EmblemHealth Medicare |
$7.35
|
| Rate for Payer: EmblemHealth Select Care |
$15.57
|
| Rate for Payer: Fidelis Medicare |
$8.24
|
| Rate for Payer: Galaxy Health Commercial |
$14.06
|
| Rate for Payer: Hamaspik Choice Medicare |
$8.00
|
| Rate for Payer: Humana Medicare |
$8.00
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$15.14
|
| Rate for Payer: Local 1199SEIU Medicare |
$9.95
|
| Rate for Payer: MVP Health Care of NY Commercial |
$16.22
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$12.18
|
| Rate for Payer: MVP Health Care of NY Medicare |
$8.40
|
| Rate for Payer: United Healthcare Medicare |
$8.00
|
| Rate for Payer: WellCare Medicare |
$11.90
|
|
|
OXYCODONE HCL 5MG TABS 10X10EA
|
Facility
|
IP
|
$6.18
|
|
|
Service Code
|
NDC 68084035401
|
| Hospital Charge Code |
4400600
|
|
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
|
|
|
OXYCODONE HCL 5MG TABS 10X10EA
|
Facility
|
OP
|
$6.18
|
|
|
Service Code
|
NDC 68084035401
|
| Hospital Charge Code |
4400600
|
|
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
|
|
|
OXYMETAZOLINE HCL 0.0005 SPIN 15 ML
|
Facility
|
OP
|
$16.22
|
|
|
Service Code
|
NDC 00085411201
|
| Hospital Charge Code |
4400023
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.51 |
| Max. Negotiated Rate |
$13.06 |
| Rate for Payer: Aetna of NY Commercial |
$11.35
|
| Rate for Payer: Aetna of NY Medicare |
$7.46
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$12.16
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$12.16
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$6.00
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$8.11
|
| Rate for Payer: Cash Price |
$12.17
|
| Rate for Payer: CDPHP Commercial |
$13.06
|
| Rate for Payer: CDPHP Medicare |
$6.00
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$12.98
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$12.98
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$12.98
|
| Rate for Payer: EmblemHealth Medicaid |
$12.98
|
| Rate for Payer: EmblemHealth Medicare |
$5.51
|
| Rate for Payer: EmblemHealth Select Care |
$11.68
|
| Rate for Payer: Fidelis Medicare |
$6.18
|
| Rate for Payer: Galaxy Health Commercial |
$10.54
|
| Rate for Payer: Hamaspik Choice Medicare |
$6.00
|
| Rate for Payer: Humana Medicare |
$6.00
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$11.35
|
| Rate for Payer: Local 1199SEIU Medicare |
$7.46
|
| Rate for Payer: MVP Health Care of NY Commercial |
$12.16
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$9.13
|
| Rate for Payer: MVP Health Care of NY Medicare |
$6.30
|
| Rate for Payer: United Healthcare Medicare |
$6.00
|
| Rate for Payer: WellCare Medicare |
$8.92
|
|
|
OXYMETAZOLINE HCL 0.0005 SPIN 15 ML
|
Facility
|
IP
|
$9.01
|
|
|
Service Code
|
NDC 00904676130
|
| Hospital Charge Code |
4400548
|
|
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
|
|
|
OXYMETAZOLINE HCL 0.0005 SPIN 15 ML
|
Facility
|
IP
|
$16.22
|
|
|
Service Code
|
NDC 00085411201
|
| Hospital Charge Code |
4400023
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.92 |
| Max. Negotiated Rate |
$10.54 |
| Rate for Payer: Cash Price |
$12.17
|
| Rate for Payer: Galaxy Health Commercial |
$10.54
|
| Rate for Payer: WellCare Medicare |
$8.92
|
|
|
OXYMETAZOLINE HCL 0.0005 SPIN 15 ML
|
Facility
|
OP
|
$9.01
|
|
|
Service Code
|
NDC 00904676130
|
| Hospital Charge Code |
4400548
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.06 |
| Max. Negotiated Rate |
$7.25 |
| 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) Blue Access/Small Group |
$6.76
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$6.76
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$3.33
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$4.50
|
| Rate for Payer: Cash Price |
$6.76
|
| Rate for Payer: CDPHP Commercial |
$7.25
|
| 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 |
$3.43
|
| Rate for Payer: Galaxy Health Commercial |
$5.86
|
| Rate for Payer: Hamaspik Choice Medicare |
$3.33
|
| Rate for Payer: Humana Medicare |
$3.33
|
| 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 |
$3.50
|
| Rate for Payer: United Healthcare Medicare |
$3.33
|
| Rate for Payer: WellCare Medicare |
$4.96
|
|
|
OXYTOCIN INJECTION TO 10 UNITS
|
Facility
|
OP
|
$6.18
|
|
|
Service Code
|
HCPCS J2590
|
| Hospital Charge Code |
4400604
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.96 |
| Max. Negotiated Rate |
$4.97 |
| Rate for Payer: Aetna of NY Commercial |
$3.40
|
| Rate for Payer: Aetna of NY Medicare |
$2.84
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$2.78
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$2.78
|
| 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: 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 |
$3.40
|
| 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: Oxford Health Plans Freedom/Liberty/Metro |
$3.20
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$1.96
|
| Rate for Payer: United Healthcare Commercial |
$3.20
|
| Rate for Payer: United Healthcare Medicare |
$2.29
|
| Rate for Payer: WellCare Medicare |
$3.40
|
|
|
OXYTOCIN INJECTION TO 10 UNITS
|
Facility
|
IP
|
$6.18
|
|
|
Service Code
|
HCPCS J2590
|
| Hospital Charge Code |
4400604
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.78 |
| Max. Negotiated Rate |
$4.02 |
| Rate for Payer: Aetna of NY Commercial |
$3.40
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$2.78
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$2.78
|
| Rate for Payer: Cash Price |
$4.64
|
| Rate for Payer: Galaxy Health Commercial |
$4.02
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$3.40
|
| Rate for Payer: WellCare Medicare |
$3.40
|
|
|
PACKED RED BLOOD CELLS (BLOOD BANK)
|
Facility
|
OP
|
$410.00
|
|
|
Service Code
|
HCPCS P9021
|
| Hospital Charge Code |
4301004
|
|
Hospital Revenue Code
|
390
|
| Min. Negotiated Rate |
$136.51 |
| Max. Negotiated Rate |
$330.05 |
| Rate for Payer: Aetna of NY Commercial |
$287.00
|
| Rate for Payer: Aetna of NY Medicare |
$188.60
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$307.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$307.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$151.70
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$205.00
|
| Rate for Payer: Cash Price |
$307.50
|
| Rate for Payer: Cash Price |
$307.50
|
| Rate for Payer: CDPHP Commercial |
$330.05
|
| Rate for Payer: CDPHP Medicare |
$151.70
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$205.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$328.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$328.00
|
| Rate for Payer: EmblemHealth Medicaid |
$328.00
|
| Rate for Payer: EmblemHealth Medicare |
$139.40
|
| Rate for Payer: EmblemHealth Select Care |
$205.00
|
| Rate for Payer: Fidelis Medicare |
$156.25
|
| Rate for Payer: Galaxy Health Commercial |
$266.50
|
| Rate for Payer: Hamaspik Choice Medicare |
$151.70
|
| Rate for Payer: Humana Medicare |
$151.70
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$287.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$188.60
|
| Rate for Payer: MVP Health Care of NY Commercial |
$307.50
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$230.83
|
| Rate for Payer: MVP Health Care of NY Medicare |
$159.28
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$307.50
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$136.51
|
| Rate for Payer: United Healthcare Commercial |
$307.50
|
| Rate for Payer: United Healthcare Medicare |
$151.70
|
| Rate for Payer: WellCare Medicare |
$225.50
|
|
|
PACKED RED BLOOD CELLS (BLOOD BANK)
|
Facility
|
IP
|
$410.00
|
|
|
Service Code
|
HCPCS P9021
|
| Hospital Charge Code |
4301004
|
|
Hospital Revenue Code
|
390
|
| Min. Negotiated Rate |
$184.50 |
| Max. Negotiated Rate |
$266.50 |
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$184.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$184.50
|
| Rate for Payer: Cash Price |
$307.50
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$205.00
|
| Rate for Payer: EmblemHealth Select Care |
$205.00
|
| Rate for Payer: Galaxy Health Commercial |
$266.50
|
| Rate for Payer: WellCare Medicare |
$225.50
|
|
|
PANTOPRAZOLE SODIUM 40MG TABS 10X10EA
|
Facility
|
OP
|
$12.62
|
|
|
Service Code
|
NDC 51079005120
|
| Hospital Charge Code |
4400606
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.29 |
| Max. Negotiated Rate |
$10.16 |
| Rate for Payer: Aetna of NY Commercial |
$8.83
|
| Rate for Payer: Aetna of NY Medicare |
$5.81
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$9.46
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$9.46
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$4.67
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$6.31
|
| Rate for Payer: Cash Price |
$9.47
|
| Rate for Payer: CDPHP Commercial |
$10.16
|
| Rate for Payer: CDPHP Medicare |
$4.67
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$10.10
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$10.10
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$10.10
|
| Rate for Payer: EmblemHealth Medicaid |
$10.10
|
| Rate for Payer: EmblemHealth Medicare |
$4.29
|
| Rate for Payer: EmblemHealth Select Care |
$9.09
|
| Rate for Payer: Fidelis Medicare |
$4.81
|
| Rate for Payer: Galaxy Health Commercial |
$8.20
|
| Rate for Payer: Hamaspik Choice Medicare |
$4.67
|
| Rate for Payer: Humana Medicare |
$4.67
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$8.83
|
| Rate for Payer: Local 1199SEIU Medicare |
$5.81
|
| Rate for Payer: MVP Health Care of NY Commercial |
$9.46
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$7.11
|
| Rate for Payer: MVP Health Care of NY Medicare |
$4.90
|
| Rate for Payer: United Healthcare Medicare |
$4.67
|
| Rate for Payer: WellCare Medicare |
$6.94
|
|
|
PANTOPRAZOLE SODIUM 40MG TABS 10X10EA
|
Facility
|
IP
|
$12.62
|
|
|
Service Code
|
NDC 51079005120
|
| Hospital Charge Code |
4400606
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.94 |
| Max. Negotiated Rate |
$8.20 |
| Rate for Payer: Cash Price |
$9.47
|
| Rate for Payer: Galaxy Health Commercial |
$8.20
|
| Rate for Payer: WellCare Medicare |
$6.94
|
|
|
PANTOPRAZOLE SODIUM, PER VIAL
|
Facility
|
IP
|
$30.15
|
|
|
Service Code
|
HCPCS J2470
|
| Hospital Charge Code |
4400667
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.57 |
| Max. Negotiated Rate |
$19.60 |
| Rate for Payer: Aetna of NY Commercial |
$16.58
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$13.57
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$13.57
|
| Rate for Payer: Cash Price |
$22.61
|
| Rate for Payer: Galaxy Health Commercial |
$19.60
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$16.58
|
| Rate for Payer: WellCare Medicare |
$16.58
|
|
|
PANTOPRAZOLE SODIUM, PER VIAL
|
Facility
|
OP
|
$30.15
|
|
|
Service Code
|
HCPCS J2470
|
| Hospital Charge Code |
4400667
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.25 |
| Max. Negotiated Rate |
$24.27 |
| Rate for Payer: Aetna of NY Commercial |
$16.58
|
| Rate for Payer: Aetna of NY Medicare |
$13.87
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$13.57
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$13.57
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$11.16
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$15.08
|
| Rate for Payer: Cash Price |
$22.61
|
| Rate for Payer: CDPHP Commercial |
$24.27
|
| Rate for Payer: CDPHP Medicare |
$11.16
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$24.12
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$24.12
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$24.12
|
| Rate for Payer: EmblemHealth Medicaid |
$24.12
|
| Rate for Payer: EmblemHealth Medicare |
$10.25
|
| Rate for Payer: EmblemHealth Select Care |
$21.71
|
| Rate for Payer: Fidelis Medicare |
$11.49
|
| Rate for Payer: Galaxy Health Commercial |
$19.60
|
| Rate for Payer: Hamaspik Choice Medicare |
$11.16
|
| Rate for Payer: Humana Medicare |
$11.16
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$16.58
|
| Rate for Payer: Local 1199SEIU Medicare |
$13.87
|
| Rate for Payer: MVP Health Care of NY Commercial |
$22.61
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$16.97
|
| Rate for Payer: MVP Health Care of NY Medicare |
$11.71
|
| Rate for Payer: United Healthcare Medicare |
$11.16
|
| Rate for Payer: WellCare Medicare |
$16.58
|
|
|
PANTOPRAZOLE TAB20MG
|
Facility
|
IP
|
$12.36
|
|
|
Service Code
|
NDC 50268063615
|
| Hospital Charge Code |
4409222
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.80 |
| Max. Negotiated Rate |
$8.03 |
| Rate for Payer: Cash Price |
$9.27
|
| Rate for Payer: Galaxy Health Commercial |
$8.03
|
| Rate for Payer: WellCare Medicare |
$6.80
|
|
|
PANTOPRAZOLE TAB20MG
|
Facility
|
OP
|
$12.36
|
|
|
Service Code
|
NDC 50268063615
|
| Hospital Charge Code |
4409222
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.20 |
| Max. Negotiated Rate |
$9.95 |
| Rate for Payer: Aetna of NY Commercial |
$8.65
|
| Rate for Payer: Aetna of NY Medicare |
$5.69
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$9.27
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$9.27
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$4.57
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$6.18
|
| Rate for Payer: Cash Price |
$9.27
|
| Rate for Payer: CDPHP Commercial |
$9.95
|
| Rate for Payer: CDPHP Medicare |
$4.57
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$9.89
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$9.89
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$9.89
|
| Rate for Payer: EmblemHealth Medicaid |
$9.89
|
| Rate for Payer: EmblemHealth Medicare |
$4.20
|
| Rate for Payer: EmblemHealth Select Care |
$8.90
|
| Rate for Payer: Fidelis Medicare |
$4.71
|
| Rate for Payer: Galaxy Health Commercial |
$8.03
|
| Rate for Payer: Hamaspik Choice Medicare |
$4.57
|
| Rate for Payer: Humana Medicare |
$4.57
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$8.65
|
| Rate for Payer: Local 1199SEIU Medicare |
$5.69
|
| Rate for Payer: MVP Health Care of NY Commercial |
$9.27
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$6.96
|
| Rate for Payer: MVP Health Care of NY Medicare |
$4.80
|
| Rate for Payer: United Healthcare Medicare |
$4.57
|
| Rate for Payer: WellCare Medicare |
$6.80
|
|
|
PARAFFIN BATH
|
Facility
|
OP
|
$24.00
|
|
|
Service Code
|
HCPCS 97018 GP
|
| Hospital Charge Code |
4650030
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$8.16 |
| Max. Negotiated Rate |
$179.00 |
| Rate for Payer: Aetna of NY Commercial |
$112.00
|
| Rate for Payer: Aetna of NY Medicare |
$11.04
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$18.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$18.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$8.88
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$108.00
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: CDPHP Commercial |
$19.32
|
| Rate for Payer: CDPHP Medicare |
$8.88
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$19.20
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$19.20
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$19.20
|
| Rate for Payer: EmblemHealth Medicaid |
$19.20
|
| Rate for Payer: EmblemHealth Medicare |
$8.16
|
| Rate for Payer: EmblemHealth Select Care |
$17.28
|
| Rate for Payer: Fidelis Medicare |
$9.15
|
| Rate for Payer: Galaxy Health Commercial |
$15.60
|
| Rate for Payer: Hamaspik Choice Medicare |
$8.88
|
| Rate for Payer: Humana Medicare |
$8.88
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$112.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$11.04
|
| Rate for Payer: MVP Health Care of NY Commercial |
$179.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$134.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$9.32
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$156.00
|
| Rate for Payer: United Healthcare Commercial |
$156.00
|
| Rate for Payer: United Healthcare Medicare |
$8.88
|
| Rate for Payer: WellCare Medicare |
$13.20
|
|
|
PARAFFIN BATH
|
Facility
|
IP
|
$24.00
|
|
|
Service Code
|
HCPCS 97018 GP
|
| Hospital Charge Code |
4650030
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$15.60 |
| Max. Negotiated Rate |
$15.60 |
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Galaxy Health Commercial |
$15.60
|
|
|
PARAFFIN BATH (MOD 59)
|
Facility
|
IP
|
$24.00
|
|
|
Service Code
|
HCPCS 97018 GP,59
|
| Hospital Charge Code |
4650374
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$15.60 |
| Max. Negotiated Rate |
$15.60 |
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Galaxy Health Commercial |
$15.60
|
|
|
PARAFFIN BATH (MOD 59)
|
Facility
|
OP
|
$24.00
|
|
|
Service Code
|
HCPCS 97018 GP,59
|
| Hospital Charge Code |
4650374
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$8.16 |
| Max. Negotiated Rate |
$179.00 |
| Rate for Payer: Aetna of NY Commercial |
$112.00
|
| Rate for Payer: Aetna of NY Medicare |
$11.04
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$18.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$18.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$8.88
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$108.00
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: CDPHP Commercial |
$19.32
|
| Rate for Payer: CDPHP Medicare |
$8.88
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$19.20
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$19.20
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$19.20
|
| Rate for Payer: EmblemHealth Medicaid |
$19.20
|
| Rate for Payer: EmblemHealth Medicare |
$8.16
|
| Rate for Payer: EmblemHealth Select Care |
$17.28
|
| Rate for Payer: Fidelis Medicare |
$9.15
|
| Rate for Payer: Galaxy Health Commercial |
$15.60
|
| Rate for Payer: Hamaspik Choice Medicare |
$8.88
|
| Rate for Payer: Humana Medicare |
$8.88
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$112.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$11.04
|
| Rate for Payer: MVP Health Care of NY Commercial |
$179.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$134.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$9.32
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$156.00
|
| Rate for Payer: United Healthcare Commercial |
$156.00
|
| Rate for Payer: United Healthcare Medicare |
$8.88
|
| Rate for Payer: WellCare Medicare |
$13.20
|
|
|
PARAFFIN BATH (MOD 59 W KX)
|
Facility
|
IP
|
$24.00
|
|
|
Service Code
|
HCPCS 97018 GP,59,KX
|
| Hospital Charge Code |
4650426
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$15.60 |
| Max. Negotiated Rate |
$15.60 |
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Galaxy Health Commercial |
$15.60
|
|
|
PARAFFIN BATH (MOD 59 W KX)
|
Facility
|
OP
|
$24.00
|
|
|
Service Code
|
HCPCS 97018 GP,59,KX
|
| Hospital Charge Code |
4650426
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$8.16 |
| Max. Negotiated Rate |
$179.00 |
| Rate for Payer: Aetna of NY Commercial |
$112.00
|
| Rate for Payer: Aetna of NY Medicare |
$11.04
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$18.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$18.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$8.88
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$108.00
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: CDPHP Commercial |
$19.32
|
| Rate for Payer: CDPHP Medicare |
$8.88
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$19.20
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$19.20
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$19.20
|
| Rate for Payer: EmblemHealth Medicaid |
$19.20
|
| Rate for Payer: EmblemHealth Medicare |
$8.16
|
| Rate for Payer: EmblemHealth Select Care |
$17.28
|
| Rate for Payer: Fidelis Medicare |
$9.15
|
| Rate for Payer: Galaxy Health Commercial |
$15.60
|
| Rate for Payer: Hamaspik Choice Medicare |
$8.88
|
| Rate for Payer: Humana Medicare |
$8.88
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$112.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$11.04
|
| Rate for Payer: MVP Health Care of NY Commercial |
$179.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$134.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$9.32
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$156.00
|
| Rate for Payer: United Healthcare Commercial |
$156.00
|
| Rate for Payer: United Healthcare Medicare |
$8.88
|
| Rate for Payer: WellCare Medicare |
$13.20
|
|
|
PARAFFIN BATH (W/ KX)
|
Facility
|
OP
|
$24.00
|
|
|
Service Code
|
HCPCS 97018 GP,KX
|
| Hospital Charge Code |
4650319
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$8.16 |
| Max. Negotiated Rate |
$179.00 |
| Rate for Payer: Aetna of NY Commercial |
$112.00
|
| Rate for Payer: Aetna of NY Medicare |
$11.04
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$18.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$18.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$8.88
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$108.00
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: CDPHP Commercial |
$19.32
|
| Rate for Payer: CDPHP Medicare |
$8.88
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$19.20
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$19.20
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$19.20
|
| Rate for Payer: EmblemHealth Medicaid |
$19.20
|
| Rate for Payer: EmblemHealth Medicare |
$8.16
|
| Rate for Payer: EmblemHealth Select Care |
$17.28
|
| Rate for Payer: Fidelis Medicare |
$9.15
|
| Rate for Payer: Galaxy Health Commercial |
$15.60
|
| Rate for Payer: Hamaspik Choice Medicare |
$8.88
|
| Rate for Payer: Humana Medicare |
$8.88
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$112.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$11.04
|
| Rate for Payer: MVP Health Care of NY Commercial |
$179.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$134.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$9.32
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$156.00
|
| Rate for Payer: United Healthcare Commercial |
$156.00
|
| Rate for Payer: United Healthcare Medicare |
$8.88
|
| Rate for Payer: WellCare Medicare |
$13.20
|
|
