|
AMMONIUM LACTATE 0.12 LOTN 225 GM
|
Facility
|
OP
|
$56.39
|
|
|
Service Code
|
NDC 45802041954
|
| Hospital Charge Code |
4400044
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.17 |
| Max. Negotiated Rate |
$45.39 |
| Rate for Payer: Aetna of NY Commercial |
$39.47
|
| Rate for Payer: Aetna of NY Medicare |
$25.94
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$42.29
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$42.29
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$20.86
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$28.20
|
| Rate for Payer: Cash Price |
$42.29
|
| Rate for Payer: CDPHP Commercial |
$45.39
|
| Rate for Payer: CDPHP Medicare |
$20.86
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$45.11
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$45.11
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$45.11
|
| Rate for Payer: EmblemHealth Medicaid |
$45.11
|
| Rate for Payer: EmblemHealth Medicare |
$19.17
|
| Rate for Payer: EmblemHealth Select Care |
$40.60
|
| Rate for Payer: Fidelis Medicare |
$21.49
|
| Rate for Payer: Galaxy Health Commercial |
$36.65
|
| Rate for Payer: Hamaspik Choice Medicare |
$20.86
|
| Rate for Payer: Humana Medicare |
$20.86
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$39.47
|
| Rate for Payer: Local 1199SEIU Medicare |
$25.94
|
| Rate for Payer: MVP Health Care of NY Commercial |
$42.29
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$31.75
|
| Rate for Payer: MVP Health Care of NY Medicare |
$21.91
|
| Rate for Payer: United Healthcare Medicare |
$20.86
|
| Rate for Payer: WellCare Medicare |
$31.01
|
|
|
AMOXICILLIN 250 MG CAP
|
Facility
|
OP
|
$6.18
|
|
|
Service Code
|
NDC 00781202001
|
| Hospital Charge Code |
4409014
|
|
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
|
|
|
AMOXICILLIN 250 MG CAP
|
Facility
|
IP
|
$6.18
|
|
|
Service Code
|
NDC 00781202001
|
| Hospital Charge Code |
4409014
|
|
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
|
|
|
AMOXICILLIN 400 MG/5 ML SUSP 400 mg, 100 mL
|
Facility
|
IP
|
$30.00
|
|
|
Service Code
|
NDC 00143988701
|
| Hospital Charge Code |
4401546
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.50 |
| Max. Negotiated Rate |
$19.50 |
| Rate for Payer: Cash Price |
$22.50
|
| Rate for Payer: Galaxy Health Commercial |
$19.50
|
| Rate for Payer: WellCare Medicare |
$16.50
|
|
|
AMOXICILLIN 400 MG/5 ML SUSP 400 mg, 100 mL
|
Facility
|
OP
|
$30.00
|
|
|
Service Code
|
NDC 00143988701
|
| Hospital Charge Code |
4401546
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.20 |
| Max. Negotiated Rate |
$24.15 |
| Rate for Payer: Aetna of NY Commercial |
$21.00
|
| Rate for Payer: Aetna of NY Medicare |
$13.80
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$22.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$22.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$11.10
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$15.00
|
| Rate for Payer: Cash Price |
$22.50
|
| Rate for Payer: CDPHP Commercial |
$24.15
|
| Rate for Payer: CDPHP Medicare |
$11.10
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$24.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$24.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$24.00
|
| Rate for Payer: EmblemHealth Medicaid |
$24.00
|
| Rate for Payer: EmblemHealth Medicare |
$10.20
|
| Rate for Payer: EmblemHealth Select Care |
$21.60
|
| Rate for Payer: Fidelis Medicare |
$11.43
|
| Rate for Payer: Galaxy Health Commercial |
$19.50
|
| Rate for Payer: Hamaspik Choice Medicare |
$11.10
|
| Rate for Payer: Humana Medicare |
$11.10
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$21.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$13.80
|
| Rate for Payer: MVP Health Care of NY Commercial |
$22.50
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$16.89
|
| Rate for Payer: MVP Health Care of NY Medicare |
$11.66
|
| Rate for Payer: United Healthcare Medicare |
$11.10
|
| Rate for Payer: WellCare Medicare |
$16.50
|
|
|
AMOXICILLIN/POT CLAVULANATE 400-57MG/5ML
|
Facility
|
IP
|
$6.18
|
|
|
Service Code
|
NDC 66685101200
|
| Hospital Charge Code |
4400049
|
|
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
|
|
|
AMOXICILLIN/POT CLAVULANATE 400-57MG/5ML
|
Facility
|
OP
|
$6.18
|
|
|
Service Code
|
NDC 66685101200
|
| Hospital Charge Code |
4400049
|
|
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
|
|
|
AMOXICILLIN/POT CLAVULANATE 500-125MG TA
|
Facility
|
OP
|
$12.45
|
|
|
Service Code
|
NDC 66685100202
|
| Hospital Charge Code |
4400050
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.23 |
| Max. Negotiated Rate |
$10.02 |
| Rate for Payer: Aetna of NY Commercial |
$8.72
|
| Rate for Payer: Aetna of NY Medicare |
$5.73
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$9.34
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$9.34
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$4.61
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$6.22
|
| Rate for Payer: Cash Price |
$9.34
|
| Rate for Payer: CDPHP Commercial |
$10.02
|
| Rate for Payer: CDPHP Medicare |
$4.61
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$9.96
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$9.96
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$9.96
|
| Rate for Payer: EmblemHealth Medicaid |
$9.96
|
| Rate for Payer: EmblemHealth Medicare |
$4.23
|
| Rate for Payer: EmblemHealth Select Care |
$8.96
|
| Rate for Payer: Fidelis Medicare |
$4.74
|
| Rate for Payer: Galaxy Health Commercial |
$8.09
|
| Rate for Payer: Hamaspik Choice Medicare |
$4.61
|
| Rate for Payer: Humana Medicare |
$4.61
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$8.72
|
| Rate for Payer: Local 1199SEIU Medicare |
$5.73
|
| Rate for Payer: MVP Health Care of NY Commercial |
$9.34
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$7.01
|
| Rate for Payer: MVP Health Care of NY Medicare |
$4.84
|
| Rate for Payer: United Healthcare Medicare |
$4.61
|
| Rate for Payer: WellCare Medicare |
$6.85
|
|
|
AMOXICILLIN/POT CLAVULANATE 500-125MG TA
|
Facility
|
IP
|
$12.45
|
|
|
Service Code
|
NDC 66685100202
|
| Hospital Charge Code |
4400050
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.85 |
| Max. Negotiated Rate |
$8.09 |
| Rate for Payer: Cash Price |
$9.34
|
| Rate for Payer: Galaxy Health Commercial |
$8.09
|
| Rate for Payer: WellCare Medicare |
$6.85
|
|
|
AMOXICILLIN/POT CLAVULANATE 875-125MG TA
|
Facility
|
IP
|
$15.19
|
|
|
Service Code
|
NDC 66685100101
|
| Hospital Charge Code |
4400051
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.35 |
| Max. Negotiated Rate |
$9.87 |
| Rate for Payer: Cash Price |
$11.39
|
| Rate for Payer: Galaxy Health Commercial |
$9.87
|
| Rate for Payer: WellCare Medicare |
$8.35
|
|
|
AMOXICILLIN/POT CLAVULANATE 875-125MG TA
|
Facility
|
OP
|
$15.19
|
|
|
Service Code
|
NDC 66685100101
|
| Hospital Charge Code |
4400051
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.16 |
| Max. Negotiated Rate |
$12.23 |
| Rate for Payer: Aetna of NY Commercial |
$10.63
|
| Rate for Payer: Aetna of NY Medicare |
$6.99
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$11.39
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$11.39
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$5.62
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$7.60
|
| Rate for Payer: Cash Price |
$11.39
|
| Rate for Payer: CDPHP Commercial |
$12.23
|
| Rate for Payer: CDPHP Medicare |
$5.62
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$12.15
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$12.15
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$12.15
|
| Rate for Payer: EmblemHealth Medicaid |
$12.15
|
| Rate for Payer: EmblemHealth Medicare |
$5.16
|
| Rate for Payer: EmblemHealth Select Care |
$10.94
|
| Rate for Payer: Fidelis Medicare |
$5.79
|
| Rate for Payer: Galaxy Health Commercial |
$9.87
|
| Rate for Payer: Hamaspik Choice Medicare |
$5.62
|
| Rate for Payer: Humana Medicare |
$5.62
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$10.63
|
| Rate for Payer: Local 1199SEIU Medicare |
$6.99
|
| Rate for Payer: MVP Health Care of NY Commercial |
$11.39
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$8.55
|
| Rate for Payer: MVP Health Care of NY Medicare |
$5.90
|
| Rate for Payer: United Healthcare Medicare |
$5.62
|
| Rate for Payer: WellCare Medicare |
$8.35
|
|
|
AMOXICILLIN TRIHYDRATE 250MG/5ML POSR 80
|
Facility
|
OP
|
$6.18
|
|
|
Service Code
|
NDC 00781604158
|
| Hospital Charge Code |
4400045
|
|
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
|
|
|
AMOXICILLIN TRIHYDRATE 250MG/5ML POSR 80
|
Facility
|
IP
|
$6.18
|
|
|
Service Code
|
NDC 00781604158
|
| Hospital Charge Code |
4400045
|
|
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
|
|
|
AMOXICILLIN TRIHYDRATE 400MG/5ML POSR 50
|
Facility
|
IP
|
$6.18
|
|
|
Service Code
|
NDC 00781615752
|
| Hospital Charge Code |
4400046
|
|
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
|
|
|
AMOXICILLIN TRIHYDRATE 400MG/5ML POSR 50
|
Facility
|
OP
|
$6.18
|
|
|
Service Code
|
NDC 00781615752
|
| Hospital Charge Code |
4400046
|
|
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
|
|
|
AMOXICILLIN TRIHYDRATE 500MG CAPS 100 EA
|
Facility
|
IP
|
$6.18
|
|
|
Service Code
|
NDC 00781261301
|
| Hospital Charge Code |
4400047
|
|
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
|
|
|
AMOXICILLIN TRIHYDRATE 500MG CAPS 100 EA
|
Facility
|
OP
|
$6.18
|
|
|
Service Code
|
NDC 00781261301
|
| Hospital Charge Code |
4400047
|
|
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
|
|
|
AMOXICILLIN TRIHYDRATE 875MG TABS 100 EA
|
Facility
|
OP
|
$6.18
|
|
|
Service Code
|
NDC 00093226401
|
| Hospital Charge Code |
4400048
|
|
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
|
|
|
AMOXICILLIN TRIHYDRATE 875MG TABS 100 EA
|
Facility
|
IP
|
$6.18
|
|
|
Service Code
|
NDC 00093226401
|
| Hospital Charge Code |
4400048
|
|
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
|
|
|
AMPICILLIN SODIUM INJ 500 MG
|
Facility
|
OP
|
$12.30
|
|
|
Service Code
|
HCPCS J0290
|
| Hospital Charge Code |
4400054
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$9.90 |
| Rate for Payer: Aetna of NY Commercial |
$6.76
|
| Rate for Payer: Aetna of NY Medicare |
$5.66
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$1.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$1.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$4.55
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$6.15
|
| Rate for Payer: Cash Price |
$9.23
|
| Rate for Payer: Cash Price |
$9.23
|
| Rate for Payer: CDPHP Commercial |
$9.90
|
| Rate for Payer: CDPHP Medicare |
$4.55
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$1.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$9.84
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$9.84
|
| Rate for Payer: EmblemHealth Medicaid |
$9.84
|
| Rate for Payer: EmblemHealth Medicare |
$4.18
|
| Rate for Payer: EmblemHealth Select Care |
$1.00
|
| Rate for Payer: Fidelis Medicare |
$4.69
|
| Rate for Payer: Galaxy Health Commercial |
$8.00
|
| Rate for Payer: Hamaspik Choice Medicare |
$4.55
|
| Rate for Payer: Humana Medicare |
$4.55
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$6.76
|
| Rate for Payer: Local 1199SEIU Medicare |
$5.66
|
| Rate for Payer: MVP Health Care of NY Commercial |
$9.22
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$6.92
|
| Rate for Payer: MVP Health Care of NY Medicare |
$4.78
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$1.29
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$1.00
|
| Rate for Payer: United Healthcare Commercial |
$1.29
|
| Rate for Payer: United Healthcare Medicare |
$4.55
|
| Rate for Payer: WellCare Medicare |
$6.76
|
|
|
AMPICILLIN SODIUM INJ 500 MG
|
Facility
|
OP
|
$9.27
|
|
|
Service Code
|
HCPCS J0290
|
| Hospital Charge Code |
4400053
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$7.46 |
| Rate for Payer: Aetna of NY Commercial |
$5.10
|
| Rate for Payer: Aetna of NY Medicare |
$4.26
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$1.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$1.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$3.43
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$4.64
|
| Rate for Payer: Cash Price |
$6.95
|
| Rate for Payer: Cash Price |
$6.95
|
| Rate for Payer: CDPHP Commercial |
$7.46
|
| Rate for Payer: CDPHP Medicare |
$3.43
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$1.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$7.42
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$7.42
|
| Rate for Payer: EmblemHealth Medicaid |
$7.42
|
| Rate for Payer: EmblemHealth Medicare |
$3.15
|
| Rate for Payer: EmblemHealth Select Care |
$1.00
|
| Rate for Payer: Fidelis Medicare |
$3.53
|
| Rate for Payer: Galaxy Health Commercial |
$6.03
|
| Rate for Payer: Hamaspik Choice Medicare |
$3.43
|
| Rate for Payer: Humana Medicare |
$3.43
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$5.10
|
| Rate for Payer: Local 1199SEIU Medicare |
$4.26
|
| Rate for Payer: MVP Health Care of NY Commercial |
$6.95
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$5.22
|
| Rate for Payer: MVP Health Care of NY Medicare |
$3.60
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$1.29
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$1.00
|
| Rate for Payer: United Healthcare Commercial |
$1.29
|
| Rate for Payer: United Healthcare Medicare |
$3.43
|
| Rate for Payer: WellCare Medicare |
$5.10
|
|
|
AMPICILLIN SODIUM INJ 500 MG
|
Facility
|
IP
|
$12.30
|
|
|
Service Code
|
HCPCS J0290
|
| Hospital Charge Code |
4400054
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$8.00 |
| Rate for Payer: Aetna of NY Commercial |
$6.76
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$1.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$1.00
|
| Rate for Payer: Cash Price |
$9.23
|
| Rate for Payer: Cash Price |
$9.23
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$1.00
|
| Rate for Payer: EmblemHealth Select Care |
$1.00
|
| Rate for Payer: Galaxy Health Commercial |
$8.00
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$6.76
|
| Rate for Payer: WellCare Medicare |
$6.76
|
|
|
AMPICILLIN SODIUM INJ 500 MG
|
Facility
|
IP
|
$9.27
|
|
|
Service Code
|
HCPCS J0290
|
| Hospital Charge Code |
4400053
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$6.03 |
| Rate for Payer: Aetna of NY Commercial |
$5.10
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$1.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$1.00
|
| Rate for Payer: Cash Price |
$6.95
|
| Rate for Payer: Cash Price |
$6.95
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$1.00
|
| Rate for Payer: EmblemHealth Select Care |
$1.00
|
| Rate for Payer: Galaxy Health Commercial |
$6.03
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$5.10
|
| Rate for Payer: WellCare Medicare |
$5.10
|
|
|
AMPICILLIN SODIUM PER 1.5 GM
|
Facility
|
IP
|
$59.23
|
|
|
Service Code
|
HCPCS J0295
|
| Hospital Charge Code |
4400058
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.12 |
| Max. Negotiated Rate |
$38.50 |
| Rate for Payer: Aetna of NY Commercial |
$32.58
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$2.12
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$2.12
|
| Rate for Payer: Cash Price |
$44.42
|
| Rate for Payer: Cash Price |
$44.42
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$2.12
|
| Rate for Payer: EmblemHealth Select Care |
$2.12
|
| Rate for Payer: Galaxy Health Commercial |
$38.50
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$32.58
|
| Rate for Payer: WellCare Medicare |
$32.58
|
|
|
AMPICILLIN SODIUM PER 1.5 GM
|
Facility
|
IP
|
$11.07
|
|
|
Service Code
|
HCPCS J0295
|
| Hospital Charge Code |
4400056
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.12 |
| Max. Negotiated Rate |
$7.20 |
| Rate for Payer: Aetna of NY Commercial |
$6.09
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$2.12
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$2.12
|
| Rate for Payer: Cash Price |
$8.30
|
| Rate for Payer: Cash Price |
$8.30
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$2.12
|
| Rate for Payer: EmblemHealth Select Care |
$2.12
|
| Rate for Payer: Galaxy Health Commercial |
$7.20
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$6.09
|
| Rate for Payer: WellCare Medicare |
$6.09
|
|
