|
POST-OP SHOE MALE XLARGE
|
Facility
|
IP
|
$46.35
|
|
| Hospital Charge Code |
4471590
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$30.13 |
| Max. Negotiated Rate |
$30.13 |
| Rate for Payer: Cash Price |
$34.76
|
| Rate for Payer: Galaxy Health Commercial |
$30.13
|
|
|
POTASSIUM
|
Facility
|
OP
|
$14.00
|
|
|
Service Code
|
HCPCS 84132
|
| Hospital Charge Code |
4300642
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$2.10 |
| Max. Negotiated Rate |
$11.20 |
| Rate for Payer: Aetna of NY Commercial |
$9.10
|
| Rate for Payer: Aetna of NY Medicare |
$6.44
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$5.60
|
| Rate for Payer: Cash Price |
$10.50
|
| Rate for Payer: CDPHP Medicare |
$5.18
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$8.40
|
| 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 |
$8.40
|
| Rate for Payer: Fidelis Medicare |
$5.60
|
| Rate for Payer: Galaxy Health Commercial |
$9.10
|
| Rate for Payer: Hamaspik Choice Medicare |
$5.60
|
| Rate for Payer: Humana Medicare |
$5.60
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$9.10
|
| 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 |
$5.88
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$10.50
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$2.10
|
| Rate for Payer: United Healthcare Commercial |
$10.50
|
| Rate for Payer: United Healthcare Medicare |
$5.60
|
| Rate for Payer: WellCare Medicare |
$7.70
|
|
|
POTASSIUM
|
Facility
|
IP
|
$14.00
|
|
|
Service Code
|
HCPCS 84132
|
| Hospital Charge Code |
4300642
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$9.10 |
| Max. Negotiated Rate |
$9.10 |
| Rate for Payer: Cash Price |
$10.50
|
| Rate for Payer: Galaxy Health Commercial |
$9.10
|
|
|
POTASSIUM CHLORIDE 10MEQ TABS 100 EA
|
Facility
|
OP
|
$6.18
|
|
|
Service Code
|
NDC 63739044610
|
| Hospital Charge Code |
4400408
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.93 |
| Max. Negotiated Rate |
$4.94 |
| Rate for Payer: Aetna of NY Commercial |
$4.33
|
| Rate for Payer: Aetna of NY Medicare |
$2.84
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$2.47
|
| Rate for Payer: Cash Price |
$4.64
|
| Rate for Payer: CDPHP Medicare |
$2.29
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$4.94
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$4.94
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$4.94
|
| Rate for Payer: EmblemHealth Medicaid |
$4.94
|
| Rate for Payer: EmblemHealth Medicare |
$2.10
|
| Rate for Payer: EmblemHealth Select Care |
$4.45
|
| Rate for Payer: Fidelis Medicare |
$2.47
|
| Rate for Payer: Galaxy Health Commercial |
$4.02
|
| Rate for Payer: Hamaspik Choice Medicare |
$2.47
|
| Rate for Payer: Humana Medicare |
$2.47
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$4.33
|
| Rate for Payer: Local 1199SEIU Medicare |
$2.84
|
| Rate for Payer: MVP Health Care of NY Commercial |
$4.63
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$3.48
|
| Rate for Payer: MVP Health Care of NY Medicare |
$2.60
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$0.93
|
| Rate for Payer: United Healthcare Medicare |
$2.47
|
| Rate for Payer: WellCare Medicare |
$3.40
|
|
|
POTASSIUM CHLORIDE 10MEQ TABS 100 EA
|
Facility
|
IP
|
$6.18
|
|
|
Service Code
|
NDC 63739044610
|
| Hospital Charge Code |
4400408
|
|
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
|
|
|
POTASSIUM CHLORIDE 20MEQ/15ML LIQD 100X1
|
Facility
|
IP
|
$24.79
|
|
|
Service Code
|
NDC 121168015
|
| Hospital Charge Code |
4400633
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.63 |
| Max. Negotiated Rate |
$16.11 |
| Rate for Payer: Cash Price |
$18.59
|
| Rate for Payer: Galaxy Health Commercial |
$16.11
|
| Rate for Payer: WellCare Medicare |
$13.63
|
|
|
POTASSIUM CHLORIDE 20MEQ/15ML LIQD 100X1
|
Facility
|
OP
|
$24.79
|
|
|
Service Code
|
NDC 121168015
|
| Hospital Charge Code |
4400633
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.72 |
| Max. Negotiated Rate |
$19.83 |
| Rate for Payer: Aetna of NY Commercial |
$17.35
|
| Rate for Payer: Aetna of NY Medicare |
$11.40
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$9.92
|
| Rate for Payer: Cash Price |
$18.59
|
| Rate for Payer: CDPHP Medicare |
$9.17
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$19.83
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$19.83
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$19.83
|
| Rate for Payer: EmblemHealth Medicaid |
$19.83
|
| Rate for Payer: EmblemHealth Medicare |
$8.43
|
| Rate for Payer: EmblemHealth Select Care |
$17.85
|
| Rate for Payer: Fidelis Medicare |
$9.92
|
| Rate for Payer: Galaxy Health Commercial |
$16.11
|
| Rate for Payer: Hamaspik Choice Medicare |
$9.92
|
| Rate for Payer: Humana Medicare |
$9.92
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$17.35
|
| Rate for Payer: Local 1199SEIU Medicare |
$11.40
|
| Rate for Payer: MVP Health Care of NY Commercial |
$18.59
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$13.96
|
| Rate for Payer: MVP Health Care of NY Medicare |
$10.41
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$3.72
|
| Rate for Payer: United Healthcare Medicare |
$9.92
|
| Rate for Payer: WellCare Medicare |
$13.63
|
|
|
POTASSIUM CHLORIDE 20MEQ TABS 100 EA
|
Facility
|
IP
|
$6.18
|
|
|
Service Code
|
NDC 781572001
|
| Hospital Charge Code |
4400632
|
|
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
|
|
|
POTASSIUM CHLORIDE 20MEQ TABS 100 EA
|
Facility
|
OP
|
$6.18
|
|
|
Service Code
|
NDC 781572001
|
| Hospital Charge Code |
4400632
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.93 |
| Max. Negotiated Rate |
$4.94 |
| Rate for Payer: Aetna of NY Commercial |
$4.33
|
| Rate for Payer: Aetna of NY Medicare |
$2.84
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$2.47
|
| Rate for Payer: Cash Price |
$4.64
|
| Rate for Payer: CDPHP Medicare |
$2.29
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$4.94
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$4.94
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$4.94
|
| Rate for Payer: EmblemHealth Medicaid |
$4.94
|
| Rate for Payer: EmblemHealth Medicare |
$2.10
|
| Rate for Payer: EmblemHealth Select Care |
$4.45
|
| Rate for Payer: Fidelis Medicare |
$2.47
|
| Rate for Payer: Galaxy Health Commercial |
$4.02
|
| Rate for Payer: Hamaspik Choice Medicare |
$2.47
|
| Rate for Payer: Humana Medicare |
$2.47
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$4.33
|
| Rate for Payer: Local 1199SEIU Medicare |
$2.84
|
| Rate for Payer: MVP Health Care of NY Commercial |
$4.63
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$3.48
|
| Rate for Payer: MVP Health Care of NY Medicare |
$2.60
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$0.93
|
| Rate for Payer: United Healthcare Medicare |
$2.47
|
| Rate for Payer: WellCare Medicare |
$3.40
|
|
|
POTASSIUM CHLORIDE INJ, PER 2 MEQ
|
Facility
|
OP
|
$9.79
|
|
|
Service Code
|
HCPCS J3480
|
| Hospital Charge Code |
4450013
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$7.83 |
| Rate for Payer: Aetna of NY Medicare |
$4.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$3.92
|
| Rate for Payer: Cash Price |
$7.34
|
| Rate for Payer: Cash Price |
$7.34
|
| Rate for Payer: CDPHP Medicare |
$3.62
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$0.13
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$7.83
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$7.83
|
| Rate for Payer: EmblemHealth Medicaid |
$7.83
|
| Rate for Payer: EmblemHealth Medicare |
$3.33
|
| Rate for Payer: EmblemHealth Select Care |
$0.13
|
| Rate for Payer: Fidelis Medicare |
$3.92
|
| Rate for Payer: Galaxy Health Commercial |
$6.36
|
| Rate for Payer: Hamaspik Choice Medicare |
$3.92
|
| Rate for Payer: Humana Medicare |
$3.92
|
| Rate for Payer: Local 1199SEIU Medicare |
$4.50
|
| Rate for Payer: MVP Health Care of NY Commercial |
$7.34
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$5.51
|
| Rate for Payer: MVP Health Care of NY Medicare |
$4.11
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$0.17
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$1.47
|
| Rate for Payer: United Healthcare Commercial |
$0.17
|
| Rate for Payer: United Healthcare Medicare |
$3.92
|
| Rate for Payer: WellCare Medicare |
$5.38
|
|
|
POTASSIUM CHLORIDE INJ, PER 2 MEQ
|
Facility
|
OP
|
$10.04
|
|
|
Service Code
|
HCPCS J3480
|
| Hospital Charge Code |
4450029
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$8.03 |
| Rate for Payer: Aetna of NY Medicare |
$4.62
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$4.02
|
| Rate for Payer: Cash Price |
$7.53
|
| Rate for Payer: Cash Price |
$7.53
|
| Rate for Payer: CDPHP Medicare |
$3.71
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$0.13
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$8.03
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$8.03
|
| Rate for Payer: EmblemHealth Medicaid |
$8.03
|
| Rate for Payer: EmblemHealth Medicare |
$3.41
|
| Rate for Payer: EmblemHealth Select Care |
$0.13
|
| Rate for Payer: Fidelis Medicare |
$4.02
|
| Rate for Payer: Galaxy Health Commercial |
$6.53
|
| Rate for Payer: Hamaspik Choice Medicare |
$4.02
|
| Rate for Payer: Humana Medicare |
$4.02
|
| Rate for Payer: Local 1199SEIU Medicare |
$4.62
|
| Rate for Payer: MVP Health Care of NY Commercial |
$7.53
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$5.65
|
| Rate for Payer: MVP Health Care of NY Medicare |
$4.22
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$0.17
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$1.51
|
| Rate for Payer: United Healthcare Commercial |
$0.17
|
| Rate for Payer: United Healthcare Medicare |
$4.02
|
| Rate for Payer: WellCare Medicare |
$5.52
|
|
|
POTASSIUM CHLORIDE INJ, PER 2 MEQ
|
Facility
|
IP
|
$10.04
|
|
|
Service Code
|
HCPCS J3480
|
| Hospital Charge Code |
4450026
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$6.53 |
| Rate for Payer: Aetna of NY Commercial |
$5.52
|
| Rate for Payer: Cash Price |
$7.53
|
| Rate for Payer: Cash Price |
$7.53
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$0.13
|
| Rate for Payer: EmblemHealth Select Care |
$0.13
|
| Rate for Payer: Galaxy Health Commercial |
$6.53
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$5.52
|
| Rate for Payer: WellCare Medicare |
$5.52
|
|
|
POTASSIUM CHLORIDE INJ, PER 2 MEQ
|
Facility
|
OP
|
$10.04
|
|
|
Service Code
|
HCPCS J3480
|
| Hospital Charge Code |
4450026
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$8.03 |
| Rate for Payer: Aetna of NY Medicare |
$4.62
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$4.02
|
| Rate for Payer: Cash Price |
$7.53
|
| Rate for Payer: Cash Price |
$7.53
|
| Rate for Payer: CDPHP Medicare |
$3.71
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$0.13
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$8.03
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$8.03
|
| Rate for Payer: EmblemHealth Medicaid |
$8.03
|
| Rate for Payer: EmblemHealth Medicare |
$3.41
|
| Rate for Payer: EmblemHealth Select Care |
$0.13
|
| Rate for Payer: Fidelis Medicare |
$4.02
|
| Rate for Payer: Galaxy Health Commercial |
$6.53
|
| Rate for Payer: Hamaspik Choice Medicare |
$4.02
|
| Rate for Payer: Humana Medicare |
$4.02
|
| Rate for Payer: Local 1199SEIU Medicare |
$4.62
|
| Rate for Payer: MVP Health Care of NY Commercial |
$7.53
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$5.65
|
| Rate for Payer: MVP Health Care of NY Medicare |
$4.22
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$0.17
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$1.51
|
| Rate for Payer: United Healthcare Commercial |
$0.17
|
| Rate for Payer: United Healthcare Medicare |
$4.02
|
| Rate for Payer: WellCare Medicare |
$5.52
|
|
|
POTASSIUM CHLORIDE INJ, PER 2 MEQ
|
Facility
|
IP
|
$10.04
|
|
|
Service Code
|
HCPCS J3480
|
| Hospital Charge Code |
4450029
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$6.53 |
| Rate for Payer: Aetna of NY Commercial |
$5.52
|
| Rate for Payer: Cash Price |
$7.53
|
| Rate for Payer: Cash Price |
$7.53
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$0.13
|
| Rate for Payer: EmblemHealth Select Care |
$0.13
|
| Rate for Payer: Galaxy Health Commercial |
$6.53
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$5.52
|
| Rate for Payer: WellCare Medicare |
$5.52
|
|
|
POTASSIUM CHLORIDE INJ, PER 2 MEQ
|
Facility
|
IP
|
$9.79
|
|
|
Service Code
|
HCPCS J3480
|
| Hospital Charge Code |
4450013
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$6.36 |
| Rate for Payer: Aetna of NY Commercial |
$5.38
|
| Rate for Payer: Cash Price |
$7.34
|
| Rate for Payer: Cash Price |
$7.34
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$0.13
|
| Rate for Payer: EmblemHealth Select Care |
$0.13
|
| Rate for Payer: Galaxy Health Commercial |
$6.36
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$5.38
|
| Rate for Payer: WellCare Medicare |
$5.38
|
|
|
POTASSIUM CL 10 MEQ/100 ML SOL 10 mEq, 100 mL
|
Facility
|
OP
|
$20.00
|
|
|
Service Code
|
HCPCS J3480
|
| Hospital Charge Code |
4401938
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$16.00 |
| Rate for Payer: Aetna of NY Medicare |
$9.20
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$8.00
|
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: CDPHP Medicare |
$7.40
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$0.13
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$16.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$16.00
|
| Rate for Payer: EmblemHealth Medicaid |
$16.00
|
| Rate for Payer: EmblemHealth Medicare |
$6.80
|
| Rate for Payer: EmblemHealth Select Care |
$0.13
|
| Rate for Payer: Fidelis Medicare |
$8.00
|
| Rate for Payer: Galaxy Health Commercial |
$13.00
|
| Rate for Payer: Hamaspik Choice Medicare |
$8.00
|
| Rate for Payer: Humana Medicare |
$8.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$9.20
|
| Rate for Payer: MVP Health Care of NY Commercial |
$15.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$11.26
|
| Rate for Payer: MVP Health Care of NY Medicare |
$8.40
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$0.17
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$3.00
|
| Rate for Payer: United Healthcare Commercial |
$0.17
|
| Rate for Payer: United Healthcare Medicare |
$8.00
|
| Rate for Payer: WellCare Medicare |
$11.00
|
|
|
POTASSIUM CL 10 MEQ/100 ML SOL 10 mEq, 100 mL
|
Facility
|
IP
|
$20.00
|
|
|
Service Code
|
HCPCS J3480
|
| Hospital Charge Code |
4401938
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$13.00 |
| Rate for Payer: Aetna of NY Commercial |
$11.00
|
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$0.13
|
| Rate for Payer: EmblemHealth Select Care |
$0.13
|
| Rate for Payer: Galaxy Health Commercial |
$13.00
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$11.00
|
| Rate for Payer: WellCare Medicare |
$11.00
|
|
|
PRAMIPEXOLE 0.125 MG TABLETS
|
Facility
|
IP
|
$9.01
|
|
|
Service Code
|
NDC 68084079325
|
| Hospital Charge Code |
4409082
|
|
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
|
|
|
PRAMIPEXOLE 0.125 MG TABLETS
|
Facility
|
OP
|
$9.01
|
|
|
Service Code
|
NDC 68084079325
|
| Hospital Charge Code |
4409082
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.35 |
| Max. Negotiated Rate |
$7.21 |
| Rate for Payer: Aetna of NY Commercial |
$6.31
|
| Rate for Payer: Aetna of NY Medicare |
$4.14
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$3.60
|
| Rate for Payer: Cash Price |
$6.76
|
| Rate for Payer: CDPHP Medicare |
$3.33
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$7.21
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$7.21
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$7.21
|
| Rate for Payer: EmblemHealth Medicaid |
$7.21
|
| Rate for Payer: EmblemHealth Medicare |
$3.06
|
| Rate for Payer: EmblemHealth Select Care |
$6.49
|
| Rate for Payer: Fidelis Medicare |
$3.60
|
| Rate for Payer: Galaxy Health Commercial |
$5.86
|
| Rate for Payer: Hamaspik Choice Medicare |
$3.60
|
| Rate for Payer: Humana Medicare |
$3.60
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$6.31
|
| Rate for Payer: Local 1199SEIU Medicare |
$4.14
|
| Rate for Payer: MVP Health Care of NY Commercial |
$6.76
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$5.07
|
| Rate for Payer: MVP Health Care of NY Medicare |
$3.78
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$1.35
|
| Rate for Payer: United Healthcare Medicare |
$3.60
|
| Rate for Payer: WellCare Medicare |
$4.96
|
|
|
PRAMIPEXOLE 0.5 MG TABLET 0.5 mg, 90 eaches
|
Facility
|
IP
|
$9.00
|
|
|
Service Code
|
NDC 13668009390
|
| Hospital Charge Code |
4401530
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.95 |
| Max. Negotiated Rate |
$5.85 |
| Rate for Payer: Cash Price |
$6.75
|
| Rate for Payer: Galaxy Health Commercial |
$5.85
|
| Rate for Payer: WellCare Medicare |
$4.95
|
|
|
PRAMIPEXOLE 0.5 MG TABLET 0.5 mg, 90 eaches
|
Facility
|
OP
|
$9.00
|
|
|
Service Code
|
NDC 13668009390
|
| Hospital Charge Code |
4401530
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.35 |
| Max. Negotiated Rate |
$7.20 |
| Rate for Payer: Aetna of NY Commercial |
$6.30
|
| Rate for Payer: Aetna of NY Medicare |
$4.14
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$3.60
|
| Rate for Payer: Cash Price |
$6.75
|
| Rate for Payer: CDPHP Medicare |
$3.33
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$7.20
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$7.20
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$7.20
|
| Rate for Payer: EmblemHealth Medicaid |
$7.20
|
| Rate for Payer: EmblemHealth Medicare |
$3.06
|
| Rate for Payer: EmblemHealth Select Care |
$6.48
|
| Rate for Payer: Fidelis Medicare |
$3.60
|
| Rate for Payer: Galaxy Health Commercial |
$5.85
|
| Rate for Payer: Hamaspik Choice Medicare |
$3.60
|
| Rate for Payer: Humana Medicare |
$3.60
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$6.30
|
| Rate for Payer: Local 1199SEIU Medicare |
$4.14
|
| Rate for Payer: MVP Health Care of NY Commercial |
$6.75
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$5.07
|
| Rate for Payer: MVP Health Care of NY Medicare |
$3.78
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$1.35
|
| Rate for Payer: United Healthcare Medicare |
$3.60
|
| Rate for Payer: WellCare Medicare |
$4.95
|
|
|
PRAMIPEXOLE 1 MG TABLET 1 mg, 30 eaches
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
NDC 68084098225
|
| Hospital Charge Code |
4401322
|
|
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
|
|
|
PRAMIPEXOLE 1 MG TABLET 1 mg, 30 eaches
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
NDC 68084098225
|
| Hospital Charge Code |
4401322
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.90 |
| Max. Negotiated Rate |
$4.80 |
| Rate for Payer: Aetna of NY Commercial |
$4.20
|
| Rate for Payer: Aetna of NY Medicare |
$2.76
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$2.40
|
| Rate for Payer: Cash Price |
$4.50
|
| Rate for Payer: CDPHP Medicare |
$2.22
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$4.80
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$4.80
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$4.80
|
| Rate for Payer: EmblemHealth Medicaid |
$4.80
|
| Rate for Payer: EmblemHealth Medicare |
$2.04
|
| Rate for Payer: EmblemHealth Select Care |
$4.32
|
| Rate for Payer: Fidelis Medicare |
$2.40
|
| Rate for Payer: Galaxy Health Commercial |
$3.90
|
| Rate for Payer: Hamaspik Choice Medicare |
$2.40
|
| Rate for Payer: Humana Medicare |
$2.40
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$4.20
|
| Rate for Payer: Local 1199SEIU Medicare |
$2.76
|
| Rate for Payer: MVP Health Care of NY Commercial |
$4.50
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$3.38
|
| Rate for Payer: MVP Health Care of NY Medicare |
$2.52
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$0.90
|
| Rate for Payer: United Healthcare Medicare |
$2.40
|
| Rate for Payer: WellCare Medicare |
$3.30
|
|
|
PRAVASTATIN SODIUM 20MG TABS 10X10EA
|
Facility
|
OP
|
$10.04
|
|
|
Service Code
|
NDC 51079045820
|
| Hospital Charge Code |
4400643
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.51 |
| Max. Negotiated Rate |
$8.03 |
| Rate for Payer: Aetna of NY Commercial |
$7.03
|
| Rate for Payer: Aetna of NY Medicare |
$4.62
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$4.02
|
| Rate for Payer: Cash Price |
$7.53
|
| Rate for Payer: CDPHP Medicare |
$3.71
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$8.03
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$8.03
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$8.03
|
| Rate for Payer: EmblemHealth Medicaid |
$8.03
|
| Rate for Payer: EmblemHealth Medicare |
$3.41
|
| Rate for Payer: EmblemHealth Select Care |
$7.23
|
| Rate for Payer: Fidelis Medicare |
$4.02
|
| Rate for Payer: Galaxy Health Commercial |
$6.53
|
| Rate for Payer: Hamaspik Choice Medicare |
$4.02
|
| Rate for Payer: Humana Medicare |
$4.02
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$7.03
|
| Rate for Payer: Local 1199SEIU Medicare |
$4.62
|
| Rate for Payer: MVP Health Care of NY Commercial |
$7.53
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$5.65
|
| Rate for Payer: MVP Health Care of NY Medicare |
$4.22
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$1.51
|
| Rate for Payer: United Healthcare Medicare |
$4.02
|
| Rate for Payer: WellCare Medicare |
$5.52
|
|
|
PRAVASTATIN SODIUM 20MG TABS 10X10EA
|
Facility
|
IP
|
$10.04
|
|
|
Service Code
|
NDC 51079045820
|
| Hospital Charge Code |
4400643
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.52 |
| Max. Negotiated Rate |
$6.53 |
| Rate for Payer: Cash Price |
$7.53
|
| Rate for Payer: Galaxy Health Commercial |
$6.53
|
| Rate for Payer: WellCare Medicare |
$5.52
|
|
