|
PREG TEST SERUM QUAL
|
Facility
|
OP
|
$40.00
|
|
|
Service Code
|
HCPCS 84703
|
| Hospital Charge Code |
4300648
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$2.02 |
| Max. Negotiated Rate |
$32.20 |
| Rate for Payer: Aetna of NY Commercial |
$26.00
|
| Rate for Payer: Aetna of NY Medicare |
$18.40
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$30.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$30.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$14.80
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$20.00
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: CDPHP Commercial |
$32.20
|
| Rate for Payer: CDPHP Medicare |
$14.80
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$24.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$32.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$32.00
|
| Rate for Payer: EmblemHealth Medicaid |
$32.00
|
| Rate for Payer: EmblemHealth Medicare |
$13.60
|
| Rate for Payer: EmblemHealth Select Care |
$24.00
|
| Rate for Payer: Fidelis Medicare |
$15.24
|
| Rate for Payer: Galaxy Health Commercial |
$26.00
|
| Rate for Payer: Hamaspik Choice Medicare |
$14.80
|
| Rate for Payer: Humana Medicare |
$14.80
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$26.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$18.40
|
| Rate for Payer: MVP Health Care of NY Commercial |
$30.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$22.52
|
| Rate for Payer: MVP Health Care of NY Medicare |
$15.54
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$30.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$2.02
|
| Rate for Payer: United Healthcare Commercial |
$30.00
|
| Rate for Payer: United Healthcare Medicare |
$14.80
|
| Rate for Payer: WellCare Medicare |
$22.00
|
|
|
PREG TEST SERUM QUAL
|
Facility
|
IP
|
$40.00
|
|
|
Service Code
|
HCPCS 84703
|
| Hospital Charge Code |
4300648
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$26.00 |
| Max. Negotiated Rate |
$26.00 |
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Galaxy Health Commercial |
$26.00
|
|
|
PREG TEST/URINE QUAL
|
Facility
|
IP
|
$40.00
|
|
|
Service Code
|
HCPCS 84703
|
| Hospital Charge Code |
4300649
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$26.00 |
| Max. Negotiated Rate |
$26.00 |
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Galaxy Health Commercial |
$26.00
|
|
|
PREG TEST/URINE QUAL
|
Facility
|
OP
|
$40.00
|
|
|
Service Code
|
HCPCS 84703
|
| Hospital Charge Code |
4300649
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$2.02 |
| Max. Negotiated Rate |
$32.20 |
| Rate for Payer: Aetna of NY Commercial |
$26.00
|
| Rate for Payer: Aetna of NY Medicare |
$18.40
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$30.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$30.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$14.80
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$20.00
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: CDPHP Commercial |
$32.20
|
| Rate for Payer: CDPHP Medicare |
$14.80
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$24.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$32.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$32.00
|
| Rate for Payer: EmblemHealth Medicaid |
$32.00
|
| Rate for Payer: EmblemHealth Medicare |
$13.60
|
| Rate for Payer: EmblemHealth Select Care |
$24.00
|
| Rate for Payer: Fidelis Medicare |
$15.24
|
| Rate for Payer: Galaxy Health Commercial |
$26.00
|
| Rate for Payer: Hamaspik Choice Medicare |
$14.80
|
| Rate for Payer: Humana Medicare |
$14.80
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$26.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$18.40
|
| Rate for Payer: MVP Health Care of NY Commercial |
$30.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$22.52
|
| Rate for Payer: MVP Health Care of NY Medicare |
$15.54
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$30.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$2.02
|
| Rate for Payer: United Healthcare Commercial |
$30.00
|
| Rate for Payer: United Healthcare Medicare |
$14.80
|
| Rate for Payer: WellCare Medicare |
$22.00
|
|
|
PRESERVISION AREDS 2 SOFTGEL 1 ea, 60 eaches
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
NDC 24208069760
|
| Hospital Charge Code |
4401458
|
|
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
|
|
|
PRESERVISION AREDS 2 SOFTGEL 1 ea, 60 eaches
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
NDC 24208069760
|
| Hospital Charge Code |
4401458
|
|
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
|
|
|
PREVACID SOLUTAB 15 MG
|
Facility
|
OP
|
$49.70
|
|
|
Service Code
|
NDC 64764054311
|
| Hospital Charge Code |
4401270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.90 |
| Max. Negotiated Rate |
$40.01 |
| Rate for Payer: Aetna of NY Commercial |
$34.79
|
| Rate for Payer: Aetna of NY Medicare |
$22.86
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$37.28
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$37.28
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$18.39
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$24.85
|
| Rate for Payer: Cash Price |
$37.28
|
| Rate for Payer: CDPHP Commercial |
$40.01
|
| Rate for Payer: CDPHP Medicare |
$18.39
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$39.76
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$39.76
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$39.76
|
| Rate for Payer: EmblemHealth Medicaid |
$39.76
|
| Rate for Payer: EmblemHealth Medicare |
$16.90
|
| Rate for Payer: EmblemHealth Select Care |
$35.78
|
| Rate for Payer: Fidelis Medicare |
$18.94
|
| Rate for Payer: Galaxy Health Commercial |
$32.30
|
| Rate for Payer: Hamaspik Choice Medicare |
$18.39
|
| Rate for Payer: Humana Medicare |
$18.39
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$34.79
|
| Rate for Payer: Local 1199SEIU Medicare |
$22.86
|
| Rate for Payer: MVP Health Care of NY Commercial |
$37.28
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$27.98
|
| Rate for Payer: MVP Health Care of NY Medicare |
$19.31
|
| Rate for Payer: United Healthcare Medicare |
$18.39
|
| Rate for Payer: WellCare Medicare |
$27.34
|
|
|
PREVACID SOLUTAB 15 MG
|
Facility
|
IP
|
$49.70
|
|
|
Service Code
|
NDC 64764054311
|
| Hospital Charge Code |
4401270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$27.34 |
| Max. Negotiated Rate |
$32.30 |
| Rate for Payer: Cash Price |
$37.28
|
| Rate for Payer: Galaxy Health Commercial |
$32.30
|
| Rate for Payer: WellCare Medicare |
$27.34
|
|
|
PRIMARY IV TUBING
|
Facility
|
OP
|
$40.00
|
|
| Hospital Charge Code |
4471895
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$13.60 |
| Max. Negotiated Rate |
$32.20 |
| Rate for Payer: Aetna of NY Commercial |
$28.00
|
| Rate for Payer: Aetna of NY Medicare |
$18.40
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$30.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$30.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$14.80
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$20.00
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: CDPHP Commercial |
$32.20
|
| Rate for Payer: CDPHP Medicare |
$14.80
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$32.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$32.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$32.00
|
| Rate for Payer: EmblemHealth Medicaid |
$32.00
|
| Rate for Payer: EmblemHealth Medicare |
$13.60
|
| Rate for Payer: EmblemHealth Select Care |
$28.80
|
| Rate for Payer: Fidelis Medicare |
$15.24
|
| Rate for Payer: Galaxy Health Commercial |
$26.00
|
| Rate for Payer: Hamaspik Choice Medicare |
$14.80
|
| Rate for Payer: Humana Medicare |
$14.80
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$28.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$18.40
|
| Rate for Payer: MVP Health Care of NY Commercial |
$30.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$22.52
|
| Rate for Payer: MVP Health Care of NY Medicare |
$15.54
|
| Rate for Payer: United Healthcare Medicare |
$14.80
|
| Rate for Payer: WellCare Medicare |
$22.00
|
|
|
PRIMARY IV TUBING
|
Facility
|
IP
|
$40.00
|
|
| Hospital Charge Code |
4471895
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$26.00 |
| Max. Negotiated Rate |
$26.00 |
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Galaxy Health Commercial |
$26.00
|
|
|
PRIMIDONE 50MG TABS 10X10EA
|
Facility
|
OP
|
$6.18
|
|
|
Service Code
|
NDC 68084020211
|
| Hospital Charge Code |
4400652
|
|
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
|
|
|
PRIMIDONE 50MG TABS 10X10EA
|
Facility
|
IP
|
$6.18
|
|
|
Service Code
|
NDC 68084020211
|
| Hospital Charge Code |
4400652
|
|
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
|
|
|
PRISM DRESSING 5562028
|
Facility
|
OP
|
$47.00
|
|
| Hospital Charge Code |
4479315
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$15.98 |
| Max. Negotiated Rate |
$37.84 |
| Rate for Payer: Aetna of NY Commercial |
$32.90
|
| Rate for Payer: Aetna of NY Medicare |
$21.62
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$35.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$35.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$17.39
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$23.50
|
| Rate for Payer: Cash Price |
$35.25
|
| Rate for Payer: CDPHP Commercial |
$37.84
|
| Rate for Payer: CDPHP Medicare |
$17.39
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$37.60
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$37.60
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$37.60
|
| Rate for Payer: EmblemHealth Medicaid |
$37.60
|
| Rate for Payer: EmblemHealth Medicare |
$15.98
|
| Rate for Payer: EmblemHealth Select Care |
$33.84
|
| Rate for Payer: Fidelis Medicare |
$17.91
|
| Rate for Payer: Galaxy Health Commercial |
$30.55
|
| Rate for Payer: Hamaspik Choice Medicare |
$17.39
|
| Rate for Payer: Humana Medicare |
$17.39
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$32.90
|
| Rate for Payer: Local 1199SEIU Medicare |
$21.62
|
| Rate for Payer: MVP Health Care of NY Commercial |
$35.25
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$26.46
|
| Rate for Payer: MVP Health Care of NY Medicare |
$18.26
|
| Rate for Payer: United Healthcare Medicare |
$17.39
|
| Rate for Payer: WellCare Medicare |
$25.85
|
|
|
PRISM DRESSING 5562028
|
Facility
|
IP
|
$47.00
|
|
| Hospital Charge Code |
4479315
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$30.55 |
| Max. Negotiated Rate |
$30.55 |
| Rate for Payer: Cash Price |
$35.25
|
| Rate for Payer: Galaxy Health Commercial |
$30.55
|
|
|
PROBE KIT GENICULAR SYSTEM
|
Facility
|
OP
|
$3,040.00
|
|
| Hospital Charge Code |
4479223
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$1,033.60 |
| Max. Negotiated Rate |
$2,447.20 |
| Rate for Payer: Aetna of NY Commercial |
$2,128.00
|
| Rate for Payer: Aetna of NY Medicare |
$1,398.40
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$2,280.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$2,280.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$1,124.80
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$1,520.00
|
| Rate for Payer: Cash Price |
$2,280.00
|
| Rate for Payer: CDPHP Commercial |
$2,447.20
|
| Rate for Payer: CDPHP Medicare |
$1,124.80
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$2,432.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$2,432.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$2,432.00
|
| Rate for Payer: EmblemHealth Medicaid |
$2,432.00
|
| Rate for Payer: EmblemHealth Medicare |
$1,033.60
|
| Rate for Payer: EmblemHealth Select Care |
$2,188.80
|
| Rate for Payer: Fidelis Medicare |
$1,158.54
|
| Rate for Payer: Galaxy Health Commercial |
$1,976.00
|
| Rate for Payer: Hamaspik Choice Medicare |
$1,124.80
|
| Rate for Payer: Humana Medicare |
$1,124.80
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$2,128.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$1,398.40
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,280.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$1,711.52
|
| Rate for Payer: MVP Health Care of NY Medicare |
$1,181.04
|
| Rate for Payer: United Healthcare Medicare |
$1,124.80
|
| Rate for Payer: WellCare Medicare |
$1,672.00
|
|
|
PROBE KIT GENICULAR SYSTEM
|
Facility
|
IP
|
$3,040.00
|
|
| Hospital Charge Code |
4479223
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$1,976.00 |
| Max. Negotiated Rate |
$1,976.00 |
| Rate for Payer: Cash Price |
$2,280.00
|
| Rate for Payer: Galaxy Health Commercial |
$1,976.00
|
|
|
PROCHLORPERAZINE 5 MG TABLET
|
Facility
|
OP
|
$6.18
|
|
|
Service Code
|
NDC 51079054120
|
| Hospital Charge Code |
4409097
|
|
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
|
|
|
PROCHLORPERAZINE 5 MG TABLET
|
Facility
|
IP
|
$6.18
|
|
|
Service Code
|
NDC 51079054120
|
| Hospital Charge Code |
4409097
|
|
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
|
|
|
PROCHLORPERAZINE INJ, UP TO 10 MG
|
Facility
|
OP
|
$68.50
|
|
|
Service Code
|
HCPCS J0780
|
| Hospital Charge Code |
4400653
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.94 |
| Max. Negotiated Rate |
$55.14 |
| Rate for Payer: Aetna of NY Commercial |
$37.68
|
| Rate for Payer: Aetna of NY Medicare |
$31.51
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$3.94
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$3.94
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$25.34
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$34.25
|
| Rate for Payer: Cash Price |
$51.38
|
| Rate for Payer: Cash Price |
$51.38
|
| Rate for Payer: CDPHP Commercial |
$55.14
|
| Rate for Payer: CDPHP Medicare |
$25.34
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$3.94
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$54.80
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$54.80
|
| Rate for Payer: EmblemHealth Medicaid |
$54.80
|
| Rate for Payer: EmblemHealth Medicare |
$23.29
|
| Rate for Payer: EmblemHealth Select Care |
$3.94
|
| Rate for Payer: Fidelis Medicare |
$26.11
|
| Rate for Payer: Galaxy Health Commercial |
$44.52
|
| Rate for Payer: Hamaspik Choice Medicare |
$25.34
|
| Rate for Payer: Humana Medicare |
$25.34
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$37.68
|
| Rate for Payer: Local 1199SEIU Medicare |
$31.51
|
| Rate for Payer: MVP Health Care of NY Commercial |
$51.38
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$38.57
|
| Rate for Payer: MVP Health Care of NY Medicare |
$26.61
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$4.97
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$3.94
|
| Rate for Payer: United Healthcare Commercial |
$4.97
|
| Rate for Payer: United Healthcare Medicare |
$25.34
|
| Rate for Payer: WellCare Medicare |
$37.68
|
|
|
PROCHLORPERAZINE INJ, UP TO 10 MG
|
Facility
|
IP
|
$68.50
|
|
|
Service Code
|
HCPCS J0780
|
| Hospital Charge Code |
4400653
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.94 |
| Max. Negotiated Rate |
$44.52 |
| Rate for Payer: Aetna of NY Commercial |
$37.68
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$3.94
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$3.94
|
| Rate for Payer: Cash Price |
$51.38
|
| Rate for Payer: Cash Price |
$51.38
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$3.94
|
| Rate for Payer: EmblemHealth Select Care |
$3.94
|
| Rate for Payer: Galaxy Health Commercial |
$44.52
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$37.68
|
| Rate for Payer: WellCare Medicare |
$37.68
|
|
|
PROCRIT 10,000 UNITS/ML VIAL 1000 unit, 1 mL
|
Facility
|
IP
|
$96.75
|
|
|
Service Code
|
HCPCS J0885
|
| Hospital Charge Code |
4401310
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.27 |
| Max. Negotiated Rate |
$62.89 |
| Rate for Payer: Aetna of NY Commercial |
$53.21
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$8.27
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$8.27
|
| Rate for Payer: Cash Price |
$72.56
|
| Rate for Payer: Cash Price |
$72.56
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$8.27
|
| Rate for Payer: EmblemHealth Select Care |
$8.27
|
| Rate for Payer: Galaxy Health Commercial |
$62.89
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$53.21
|
| Rate for Payer: WellCare Medicare |
$53.21
|
|
|
PROCRIT 10,000 UNITS/ML VIAL 1000 unit, 1 mL
|
Facility
|
OP
|
$96.75
|
|
|
Service Code
|
HCPCS J0885
|
| Hospital Charge Code |
4401310
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.27 |
| Max. Negotiated Rate |
$1,226.00 |
| Rate for Payer: Aetna of NY Commercial |
$53.21
|
| Rate for Payer: Aetna of NY Medicare |
$44.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$8.27
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$8.27
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Essential Plan |
$27.58
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicaid |
$12.26
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$35.80
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$48.38
|
| Rate for Payer: Cash Price |
$72.56
|
| Rate for Payer: Cash Price |
$72.56
|
| Rate for Payer: CDPHP Child Health Plus/HARP/Select Plan |
$12.26
|
| Rate for Payer: CDPHP Commercial |
$77.88
|
| Rate for Payer: CDPHP Essential Plan |
$27.58
|
| Rate for Payer: CDPHP Medicare |
$35.80
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$8.27
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$14.71
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$12.26
|
| Rate for Payer: EmblemHealth Medicaid |
$12.26
|
| Rate for Payer: EmblemHealth Medicare |
$32.90
|
| Rate for Payer: EmblemHealth Select Care |
$8.27
|
| Rate for Payer: Fidelis Child Health Plus/Essential Plan/HARP/Medicaid |
$27.58
|
| Rate for Payer: Fidelis Medicare |
$36.87
|
| Rate for Payer: Galaxy Health Commercial |
$62.89
|
| Rate for Payer: Galaxy Health Workers Comp |
$18.02
|
| Rate for Payer: Hamaspik Choice Medicaid |
$1,226.00
|
| Rate for Payer: Hamaspik Choice Medicare |
$35.80
|
| Rate for Payer: Humana Medicare |
$35.80
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$53.21
|
| Rate for Payer: Local 1199SEIU Medicare |
$44.50
|
| Rate for Payer: MVP Health Care of NY Child Health Plus/Family Health Plus/HARP/Medicaid |
$1,226.00
|
| Rate for Payer: MVP Health Care of NY Commercial |
$72.56
|
| Rate for Payer: MVP Health Care of NY Essential Plan 1&2 |
$26.36
|
| Rate for Payer: MVP Health Care of NY Essential Plan 3&4 |
$26.36
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$54.47
|
| Rate for Payer: MVP Health Care of NY Medicare |
$37.59
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$11.35
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$12.26
|
| Rate for Payer: United Healthcare Commercial |
$11.35
|
| Rate for Payer: United Healthcare Medicare |
$35.80
|
| Rate for Payer: WellCare Child Health Plus/Family Health Plus/Medicaid |
$12.87
|
| Rate for Payer: WellCare Medicare |
$53.21
|
|
|
PROCRIT 40,000 UNITS/ML VIAL 40000 UNIT, 1 ML
|
Facility
|
OP
|
$97.00
|
|
|
Service Code
|
HCPCS J0885
|
| Hospital Charge Code |
4401301
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.27 |
| Max. Negotiated Rate |
$1,226.00 |
| Rate for Payer: Aetna of NY Commercial |
$53.35
|
| Rate for Payer: Aetna of NY Medicare |
$44.62
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$8.27
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$8.27
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Essential Plan |
$27.58
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicaid |
$12.26
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$35.89
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$48.50
|
| Rate for Payer: Cash Price |
$72.75
|
| Rate for Payer: Cash Price |
$72.75
|
| Rate for Payer: CDPHP Child Health Plus/HARP/Select Plan |
$12.26
|
| Rate for Payer: CDPHP Commercial |
$78.08
|
| Rate for Payer: CDPHP Essential Plan |
$27.58
|
| Rate for Payer: CDPHP Medicare |
$35.89
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$8.27
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$14.71
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$12.26
|
| Rate for Payer: EmblemHealth Medicaid |
$12.26
|
| Rate for Payer: EmblemHealth Medicare |
$32.98
|
| Rate for Payer: EmblemHealth Select Care |
$8.27
|
| Rate for Payer: Fidelis Child Health Plus/Essential Plan/HARP/Medicaid |
$27.58
|
| Rate for Payer: Fidelis Medicare |
$36.97
|
| Rate for Payer: Galaxy Health Commercial |
$63.05
|
| Rate for Payer: Galaxy Health Workers Comp |
$18.02
|
| Rate for Payer: Hamaspik Choice Medicaid |
$1,226.00
|
| Rate for Payer: Hamaspik Choice Medicare |
$35.89
|
| Rate for Payer: Humana Medicare |
$35.89
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$53.35
|
| Rate for Payer: Local 1199SEIU Medicare |
$44.62
|
| Rate for Payer: MVP Health Care of NY Child Health Plus/Family Health Plus/HARP/Medicaid |
$1,226.00
|
| Rate for Payer: MVP Health Care of NY Commercial |
$72.75
|
| Rate for Payer: MVP Health Care of NY Essential Plan 1&2 |
$26.36
|
| Rate for Payer: MVP Health Care of NY Essential Plan 3&4 |
$26.36
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$54.61
|
| Rate for Payer: MVP Health Care of NY Medicare |
$37.68
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$11.35
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$12.26
|
| Rate for Payer: United Healthcare Commercial |
$11.35
|
| Rate for Payer: United Healthcare Medicare |
$35.89
|
| Rate for Payer: WellCare Child Health Plus/Family Health Plus/Medicaid |
$12.87
|
| Rate for Payer: WellCare Medicare |
$53.35
|
|
|
PROCRIT 40,000 UNITS/ML VIAL 40000 UNIT, 1 ML
|
Facility
|
IP
|
$97.00
|
|
|
Service Code
|
HCPCS J0885
|
| Hospital Charge Code |
4401301
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.27 |
| Max. Negotiated Rate |
$63.05 |
| Rate for Payer: Aetna of NY Commercial |
$53.35
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$8.27
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$8.27
|
| Rate for Payer: Cash Price |
$72.75
|
| Rate for Payer: Cash Price |
$72.75
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$8.27
|
| Rate for Payer: EmblemHealth Select Care |
$8.27
|
| Rate for Payer: Galaxy Health Commercial |
$63.05
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$53.35
|
| Rate for Payer: WellCare Medicare |
$53.35
|
|
|
PROGRAMER KIT SC5500-04 BOS SCIENTIFIC
|
Facility
|
IP
|
$5,028.00
|
|
| Hospital Charge Code |
4479092
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,262.60 |
| Max. Negotiated Rate |
$3,519.60 |
| Rate for Payer: Aetna of NY Commercial |
$3,519.60
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$2,262.60
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$2,262.60
|
| Rate for Payer: Cash Price |
$3,771.00
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$2,514.00
|
| Rate for Payer: EmblemHealth Select Care |
$2,514.00
|
| Rate for Payer: Galaxy Health Commercial |
$3,268.20
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$3,519.60
|
| Rate for Payer: Multiplan Commercial |
$2,262.60
|
| Rate for Payer: MVP Health Care of NY Commercial |
$3,268.20
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$3,268.20
|
| Rate for Payer: WellCare Medicare |
$2,765.40
|
|
