|
TOBRADEX OO
|
Facility
|
OP
|
$726.15
|
|
|
Service Code
|
NDC 00065064835
|
| Hospital Charge Code |
4408998
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$246.89 |
| Max. Negotiated Rate |
$584.55 |
| Rate for Payer: Aetna of NY Commercial |
$508.30
|
| Rate for Payer: Aetna of NY Medicare |
$334.03
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$544.61
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$544.61
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$268.68
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$363.08
|
| Rate for Payer: Cash Price |
$544.61
|
| Rate for Payer: CDPHP Commercial |
$584.55
|
| Rate for Payer: CDPHP Medicare |
$268.68
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$580.92
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$580.92
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$580.92
|
| Rate for Payer: EmblemHealth Medicaid |
$580.92
|
| Rate for Payer: EmblemHealth Medicare |
$246.89
|
| Rate for Payer: EmblemHealth Select Care |
$522.83
|
| Rate for Payer: Fidelis Medicare |
$276.74
|
| Rate for Payer: Galaxy Health Commercial |
$472.00
|
| Rate for Payer: Hamaspik Choice Medicare |
$268.68
|
| Rate for Payer: Humana Medicare |
$268.68
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$508.30
|
| Rate for Payer: Local 1199SEIU Medicare |
$334.03
|
| Rate for Payer: MVP Health Care of NY Commercial |
$544.61
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$408.82
|
| Rate for Payer: MVP Health Care of NY Medicare |
$282.11
|
| Rate for Payer: United Healthcare Medicare |
$268.68
|
| Rate for Payer: WellCare Medicare |
$399.38
|
|
|
TOBRADEX OO
|
Facility
|
IP
|
$726.15
|
|
|
Service Code
|
NDC 00065064835
|
| Hospital Charge Code |
4408998
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$399.38 |
| Max. Negotiated Rate |
$472.00 |
| Rate for Payer: Cash Price |
$544.61
|
| Rate for Payer: Galaxy Health Commercial |
$472.00
|
| Rate for Payer: WellCare Medicare |
$399.38
|
|
|
TOBRAMYCIN/DEXAMETHASONE 0.3-0.1% DROP 5
|
Facility
|
IP
|
$80.86
|
|
|
Service Code
|
NDC 24208029505
|
| Hospital Charge Code |
4400763
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$44.47 |
| Max. Negotiated Rate |
$52.56 |
| Rate for Payer: Cash Price |
$60.65
|
| Rate for Payer: Galaxy Health Commercial |
$52.56
|
| Rate for Payer: WellCare Medicare |
$44.47
|
|
|
TOBRAMYCIN/DEXAMETHASONE 0.3-0.1% DROP 5
|
Facility
|
OP
|
$80.86
|
|
|
Service Code
|
NDC 24208029505
|
| Hospital Charge Code |
4400763
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$27.49 |
| Max. Negotiated Rate |
$65.09 |
| Rate for Payer: Aetna of NY Commercial |
$56.60
|
| Rate for Payer: Aetna of NY Medicare |
$37.20
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$60.64
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$60.64
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$29.92
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$40.43
|
| Rate for Payer: Cash Price |
$60.65
|
| Rate for Payer: CDPHP Commercial |
$65.09
|
| Rate for Payer: CDPHP Medicare |
$29.92
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$64.69
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$64.69
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$64.69
|
| Rate for Payer: EmblemHealth Medicaid |
$64.69
|
| Rate for Payer: EmblemHealth Medicare |
$27.49
|
| Rate for Payer: EmblemHealth Select Care |
$58.22
|
| Rate for Payer: Fidelis Medicare |
$30.82
|
| Rate for Payer: Galaxy Health Commercial |
$52.56
|
| Rate for Payer: Hamaspik Choice Medicare |
$29.92
|
| Rate for Payer: Humana Medicare |
$29.92
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$56.60
|
| Rate for Payer: Local 1199SEIU Medicare |
$37.20
|
| Rate for Payer: MVP Health Care of NY Commercial |
$60.64
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$45.52
|
| Rate for Payer: MVP Health Care of NY Medicare |
$31.41
|
| Rate for Payer: United Healthcare Medicare |
$29.92
|
| Rate for Payer: WellCare Medicare |
$44.47
|
|
|
TOBRAMYCIN OS
|
Facility
|
OP
|
$45.06
|
|
|
Service Code
|
NDC 17478029010
|
| Hospital Charge Code |
4409000
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.32 |
| Max. Negotiated Rate |
$36.27 |
| Rate for Payer: Aetna of NY Commercial |
$31.54
|
| Rate for Payer: Aetna of NY Medicare |
$20.73
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$33.80
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$33.80
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$16.67
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$22.53
|
| Rate for Payer: Cash Price |
$33.80
|
| Rate for Payer: CDPHP Commercial |
$36.27
|
| Rate for Payer: CDPHP Medicare |
$16.67
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$36.05
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$36.05
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$36.05
|
| Rate for Payer: EmblemHealth Medicaid |
$36.05
|
| Rate for Payer: EmblemHealth Medicare |
$15.32
|
| Rate for Payer: EmblemHealth Select Care |
$32.44
|
| Rate for Payer: Fidelis Medicare |
$17.17
|
| Rate for Payer: Galaxy Health Commercial |
$29.29
|
| Rate for Payer: Hamaspik Choice Medicare |
$16.67
|
| Rate for Payer: Humana Medicare |
$16.67
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$31.54
|
| Rate for Payer: Local 1199SEIU Medicare |
$20.73
|
| Rate for Payer: MVP Health Care of NY Commercial |
$33.80
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$25.37
|
| Rate for Payer: MVP Health Care of NY Medicare |
$17.51
|
| Rate for Payer: United Healthcare Medicare |
$16.67
|
| Rate for Payer: WellCare Medicare |
$24.78
|
|
|
TOBRAMYCIN OS
|
Facility
|
IP
|
$45.06
|
|
|
Service Code
|
NDC 17478029010
|
| Hospital Charge Code |
4409000
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.78 |
| Max. Negotiated Rate |
$29.29 |
| Rate for Payer: Cash Price |
$33.80
|
| Rate for Payer: Galaxy Health Commercial |
$29.29
|
| Rate for Payer: WellCare Medicare |
$24.78
|
|
|
TOBREX OO
|
Facility
|
OP
|
$714.05
|
|
|
Service Code
|
NDC 00065064435
|
| Hospital Charge Code |
4408999
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$242.78 |
| Max. Negotiated Rate |
$574.81 |
| Rate for Payer: Aetna of NY Commercial |
$499.84
|
| Rate for Payer: Aetna of NY Medicare |
$328.46
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$535.54
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$535.54
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$264.20
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$357.02
|
| Rate for Payer: Cash Price |
$535.54
|
| Rate for Payer: CDPHP Commercial |
$574.81
|
| Rate for Payer: CDPHP Medicare |
$264.20
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$571.24
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$571.24
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$571.24
|
| Rate for Payer: EmblemHealth Medicaid |
$571.24
|
| Rate for Payer: EmblemHealth Medicare |
$242.78
|
| Rate for Payer: EmblemHealth Select Care |
$514.12
|
| Rate for Payer: Fidelis Medicare |
$272.12
|
| Rate for Payer: Galaxy Health Commercial |
$464.13
|
| Rate for Payer: Hamaspik Choice Medicare |
$264.20
|
| Rate for Payer: Humana Medicare |
$264.20
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$499.84
|
| Rate for Payer: Local 1199SEIU Medicare |
$328.46
|
| Rate for Payer: MVP Health Care of NY Commercial |
$535.54
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$402.01
|
| Rate for Payer: MVP Health Care of NY Medicare |
$277.41
|
| Rate for Payer: United Healthcare Medicare |
$264.20
|
| Rate for Payer: WellCare Medicare |
$392.73
|
|
|
TOBREX OO
|
Facility
|
IP
|
$714.05
|
|
|
Service Code
|
NDC 00065064435
|
| Hospital Charge Code |
4408999
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$392.73 |
| Max. Negotiated Rate |
$464.13 |
| Rate for Payer: Cash Price |
$535.54
|
| Rate for Payer: Galaxy Health Commercial |
$464.13
|
| Rate for Payer: WellCare Medicare |
$392.73
|
|
|
TOMOSYNTHESIS, MAMMO
|
Facility
|
OP
|
$194.00
|
|
|
Service Code
|
HCPCS G0279 TC
|
| Hospital Charge Code |
4150404
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$65.96 |
| Max. Negotiated Rate |
$475.00 |
| Rate for Payer: Aetna of NY Commercial |
$116.40
|
| Rate for Payer: Aetna of NY Medicare |
$89.24
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$145.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$145.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$71.78
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$97.00
|
| Rate for Payer: Cash Price |
$145.50
|
| Rate for Payer: Cash Price |
$145.50
|
| Rate for Payer: CDPHP Commercial |
$156.17
|
| Rate for Payer: CDPHP Medicare |
$71.78
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$135.80
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$155.20
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$155.20
|
| Rate for Payer: EmblemHealth Medicaid |
$155.20
|
| Rate for Payer: EmblemHealth Medicare |
$65.96
|
| Rate for Payer: EmblemHealth Select Care |
$126.10
|
| Rate for Payer: Fidelis Medicare |
$73.93
|
| Rate for Payer: Galaxy Health Commercial |
$126.10
|
| Rate for Payer: Hamaspik Choice Medicare |
$71.78
|
| Rate for Payer: Humana Medicare |
$71.78
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$116.40
|
| Rate for Payer: Local 1199SEIU Medicare |
$89.24
|
| Rate for Payer: MVP Health Care of NY Commercial |
$145.50
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$109.22
|
| Rate for Payer: MVP Health Care of NY Medicare |
$75.37
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$475.00
|
| Rate for Payer: United Healthcare Commercial |
$475.00
|
| Rate for Payer: United Healthcare Medicare |
$71.78
|
| Rate for Payer: WellCare Medicare |
$106.70
|
|
|
TOMOSYNTHESIS, MAMMO
|
Facility
|
IP
|
$194.00
|
|
|
Service Code
|
HCPCS G0279 TC
|
| Hospital Charge Code |
4150404
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$126.10 |
| Max. Negotiated Rate |
$126.10 |
| Rate for Payer: Cash Price |
$145.50
|
| Rate for Payer: Galaxy Health Commercial |
$126.10
|
|
|
TOMOSYNTHESIS, MAMMO, LEFT
|
Facility
|
OP
|
$194.00
|
|
|
Service Code
|
HCPCS G0279 LT,TC
|
| Hospital Charge Code |
4150410
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$65.96 |
| Max. Negotiated Rate |
$475.00 |
| Rate for Payer: Aetna of NY Commercial |
$116.40
|
| Rate for Payer: Aetna of NY Medicare |
$89.24
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$145.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$145.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$71.78
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$97.00
|
| Rate for Payer: Cash Price |
$145.50
|
| Rate for Payer: Cash Price |
$145.50
|
| Rate for Payer: CDPHP Commercial |
$156.17
|
| Rate for Payer: CDPHP Medicare |
$71.78
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$135.80
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$155.20
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$155.20
|
| Rate for Payer: EmblemHealth Medicaid |
$155.20
|
| Rate for Payer: EmblemHealth Medicare |
$65.96
|
| Rate for Payer: EmblemHealth Select Care |
$126.10
|
| Rate for Payer: Fidelis Medicare |
$73.93
|
| Rate for Payer: Galaxy Health Commercial |
$126.10
|
| Rate for Payer: Hamaspik Choice Medicare |
$71.78
|
| Rate for Payer: Humana Medicare |
$71.78
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$116.40
|
| Rate for Payer: Local 1199SEIU Medicare |
$89.24
|
| Rate for Payer: MVP Health Care of NY Commercial |
$145.50
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$109.22
|
| Rate for Payer: MVP Health Care of NY Medicare |
$75.37
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$475.00
|
| Rate for Payer: United Healthcare Commercial |
$475.00
|
| Rate for Payer: United Healthcare Medicare |
$71.78
|
| Rate for Payer: WellCare Medicare |
$106.70
|
|
|
TOMOSYNTHESIS, MAMMO, LEFT
|
Facility
|
IP
|
$194.00
|
|
|
Service Code
|
HCPCS G0279 LT,TC
|
| Hospital Charge Code |
4150410
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$126.10 |
| Max. Negotiated Rate |
$126.10 |
| Rate for Payer: Cash Price |
$145.50
|
| Rate for Payer: Galaxy Health Commercial |
$126.10
|
|
|
TOMOSYNTHESIS, MAMMO, RIGHT
|
Facility
|
IP
|
$194.00
|
|
|
Service Code
|
HCPCS G0279 RT,TC
|
| Hospital Charge Code |
4150411
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$126.10 |
| Max. Negotiated Rate |
$126.10 |
| Rate for Payer: Cash Price |
$145.50
|
| Rate for Payer: Galaxy Health Commercial |
$126.10
|
|
|
TOMOSYNTHESIS, MAMMO, RIGHT
|
Facility
|
OP
|
$194.00
|
|
|
Service Code
|
HCPCS G0279 RT,TC
|
| Hospital Charge Code |
4150411
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$65.96 |
| Max. Negotiated Rate |
$475.00 |
| Rate for Payer: Aetna of NY Commercial |
$116.40
|
| Rate for Payer: Aetna of NY Medicare |
$89.24
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$145.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$145.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$71.78
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$97.00
|
| Rate for Payer: Cash Price |
$145.50
|
| Rate for Payer: Cash Price |
$145.50
|
| Rate for Payer: CDPHP Commercial |
$156.17
|
| Rate for Payer: CDPHP Medicare |
$71.78
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$135.80
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$155.20
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$155.20
|
| Rate for Payer: EmblemHealth Medicaid |
$155.20
|
| Rate for Payer: EmblemHealth Medicare |
$65.96
|
| Rate for Payer: EmblemHealth Select Care |
$126.10
|
| Rate for Payer: Fidelis Medicare |
$73.93
|
| Rate for Payer: Galaxy Health Commercial |
$126.10
|
| Rate for Payer: Hamaspik Choice Medicare |
$71.78
|
| Rate for Payer: Humana Medicare |
$71.78
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$116.40
|
| Rate for Payer: Local 1199SEIU Medicare |
$89.24
|
| Rate for Payer: MVP Health Care of NY Commercial |
$145.50
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$109.22
|
| Rate for Payer: MVP Health Care of NY Medicare |
$75.37
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$475.00
|
| Rate for Payer: United Healthcare Commercial |
$475.00
|
| Rate for Payer: United Healthcare Medicare |
$71.78
|
| Rate for Payer: WellCare Medicare |
$106.70
|
|
|
TOPAMAX (TOPIRAMATE)
|
Facility
|
OP
|
$169.00
|
|
|
Service Code
|
HCPCS 80201
|
| Hospital Charge Code |
4301167
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.92 |
| Max. Negotiated Rate |
$136.04 |
| Rate for Payer: Aetna of NY Commercial |
$109.85
|
| Rate for Payer: Aetna of NY Medicare |
$77.74
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$126.75
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$126.75
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$62.53
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$84.50
|
| Rate for Payer: Cash Price |
$126.75
|
| Rate for Payer: Cash Price |
$126.75
|
| Rate for Payer: CDPHP Commercial |
$136.04
|
| Rate for Payer: CDPHP Medicare |
$62.53
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$101.40
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$135.20
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$135.20
|
| Rate for Payer: EmblemHealth Medicaid |
$135.20
|
| Rate for Payer: EmblemHealth Medicare |
$57.46
|
| Rate for Payer: EmblemHealth Select Care |
$101.40
|
| Rate for Payer: Fidelis Medicare |
$64.41
|
| Rate for Payer: Galaxy Health Commercial |
$109.85
|
| Rate for Payer: Hamaspik Choice Medicare |
$62.53
|
| Rate for Payer: Humana Medicare |
$62.53
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$109.85
|
| Rate for Payer: Local 1199SEIU Medicare |
$77.74
|
| Rate for Payer: MVP Health Care of NY Commercial |
$126.75
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$95.15
|
| Rate for Payer: MVP Health Care of NY Medicare |
$65.66
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$126.75
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$11.92
|
| Rate for Payer: United Healthcare Commercial |
$126.75
|
| Rate for Payer: United Healthcare Medicare |
$62.53
|
| Rate for Payer: WellCare Medicare |
$92.95
|
|
|
TOPAMAX (TOPIRAMATE)
|
Facility
|
IP
|
$169.00
|
|
|
Service Code
|
HCPCS 80201
|
| Hospital Charge Code |
4301167
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$109.85 |
| Max. Negotiated Rate |
$109.85 |
| Rate for Payer: Cash Price |
$126.75
|
| Rate for Payer: Galaxy Health Commercial |
$109.85
|
|
|
TOPIRAMATE 25MG TABS 10X10EA
|
Facility
|
IP
|
$6.44
|
|
|
Service Code
|
NDC 68084034211
|
| Hospital Charge Code |
4400764
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.54 |
| Max. Negotiated Rate |
$4.19 |
| Rate for Payer: Cash Price |
$4.83
|
| Rate for Payer: Galaxy Health Commercial |
$4.19
|
| Rate for Payer: WellCare Medicare |
$3.54
|
|
|
TOPIRAMATE 25MG TABS 10X10EA
|
Facility
|
OP
|
$6.44
|
|
|
Service Code
|
NDC 68084034211
|
| Hospital Charge Code |
4400764
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.19 |
| Max. Negotiated Rate |
$5.18 |
| Rate for Payer: Aetna of NY Commercial |
$4.51
|
| Rate for Payer: Aetna of NY Medicare |
$2.96
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$4.83
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$4.83
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$2.38
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$3.22
|
| Rate for Payer: Cash Price |
$4.83
|
| Rate for Payer: CDPHP Commercial |
$5.18
|
| Rate for Payer: CDPHP Medicare |
$2.38
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$5.15
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$5.15
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$5.15
|
| Rate for Payer: EmblemHealth Medicaid |
$5.15
|
| Rate for Payer: EmblemHealth Medicare |
$2.19
|
| Rate for Payer: EmblemHealth Select Care |
$4.64
|
| Rate for Payer: Fidelis Medicare |
$2.45
|
| Rate for Payer: Galaxy Health Commercial |
$4.19
|
| Rate for Payer: Hamaspik Choice Medicare |
$2.38
|
| Rate for Payer: Humana Medicare |
$2.38
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$4.51
|
| Rate for Payer: Local 1199SEIU Medicare |
$2.96
|
| Rate for Payer: MVP Health Care of NY Commercial |
$4.83
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$3.63
|
| Rate for Payer: MVP Health Care of NY Medicare |
$2.50
|
| Rate for Payer: United Healthcare Medicare |
$2.38
|
| Rate for Payer: WellCare Medicare |
$3.54
|
|
|
TORSEMIDE 20 MG PO
|
Facility
|
OP
|
$6.18
|
|
|
Service Code
|
NDC 68084053901
|
| Hospital Charge Code |
4409054
|
|
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
|
|
|
TORSEMIDE 20 MG PO
|
Facility
|
IP
|
$6.18
|
|
|
Service Code
|
NDC 68084053901
|
| Hospital Charge Code |
4409054
|
|
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
|
|
|
TORSEMIDE TABLET 5 MG
|
Facility
|
OP
|
$6.18
|
|
|
Service Code
|
NDC 50268075415
|
| Hospital Charge Code |
4400842
|
|
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
|
|
|
TORSEMIDE TABLET 5 MG
|
Facility
|
IP
|
$6.18
|
|
|
Service Code
|
NDC 50268075415
|
| Hospital Charge Code |
4400842
|
|
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
|
|
|
TOTAL PROTEIN OTHER SPECIMEN
|
Facility
|
IP
|
$49.00
|
|
|
Service Code
|
HCPCS 84157
|
| Hospital Charge Code |
4300894
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$31.85 |
| Max. Negotiated Rate |
$31.85 |
| Rate for Payer: Cash Price |
$36.75
|
| Rate for Payer: Galaxy Health Commercial |
$31.85
|
|
|
TOTAL PROTEIN OTHER SPECIMEN
|
Facility
|
OP
|
$49.00
|
|
|
Service Code
|
HCPCS 84157
|
| Hospital Charge Code |
4300894
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$4.00 |
| Max. Negotiated Rate |
$39.44 |
| Rate for Payer: Aetna of NY Commercial |
$31.85
|
| Rate for Payer: Aetna of NY Medicare |
$22.54
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$36.75
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$36.75
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$18.13
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$24.50
|
| Rate for Payer: Cash Price |
$36.75
|
| Rate for Payer: Cash Price |
$36.75
|
| Rate for Payer: CDPHP Commercial |
$39.44
|
| Rate for Payer: CDPHP Medicare |
$18.13
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$29.40
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$39.20
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$39.20
|
| Rate for Payer: EmblemHealth Medicaid |
$39.20
|
| Rate for Payer: EmblemHealth Medicare |
$16.66
|
| Rate for Payer: EmblemHealth Select Care |
$29.40
|
| Rate for Payer: Fidelis Medicare |
$18.67
|
| Rate for Payer: Galaxy Health Commercial |
$31.85
|
| Rate for Payer: Hamaspik Choice Medicare |
$18.13
|
| Rate for Payer: Humana Medicare |
$18.13
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$31.85
|
| Rate for Payer: Local 1199SEIU Medicare |
$22.54
|
| Rate for Payer: MVP Health Care of NY Commercial |
$36.75
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$27.59
|
| Rate for Payer: MVP Health Care of NY Medicare |
$19.04
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$36.75
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$4.00
|
| Rate for Payer: United Healthcare Commercial |
$36.75
|
| Rate for Payer: United Healthcare Medicare |
$18.13
|
| Rate for Payer: WellCare Medicare |
$26.95
|
|
|
TOXIN ASSAY TISSUE CULTURE
|
Facility
|
OP
|
$103.00
|
|
|
Service Code
|
HCPCS 87230
|
| Hospital Charge Code |
4301205
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$9.49 |
| Max. Negotiated Rate |
$82.92 |
| Rate for Payer: Aetna of NY Commercial |
$66.95
|
| Rate for Payer: Aetna of NY Medicare |
$47.38
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$77.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$77.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$38.11
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$51.50
|
| Rate for Payer: Cash Price |
$77.25
|
| Rate for Payer: Cash Price |
$77.25
|
| Rate for Payer: CDPHP Commercial |
$82.92
|
| Rate for Payer: CDPHP Medicare |
$38.11
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$61.80
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$82.40
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$82.40
|
| Rate for Payer: EmblemHealth Medicaid |
$82.40
|
| Rate for Payer: EmblemHealth Medicare |
$35.02
|
| Rate for Payer: EmblemHealth Select Care |
$61.80
|
| Rate for Payer: Fidelis Medicare |
$39.25
|
| Rate for Payer: Galaxy Health Commercial |
$66.95
|
| Rate for Payer: Hamaspik Choice Medicare |
$38.11
|
| Rate for Payer: Humana Medicare |
$38.11
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$66.95
|
| Rate for Payer: Local 1199SEIU Medicare |
$47.38
|
| Rate for Payer: MVP Health Care of NY Commercial |
$77.25
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$57.99
|
| Rate for Payer: MVP Health Care of NY Medicare |
$40.02
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$77.25
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$9.49
|
| Rate for Payer: United Healthcare Commercial |
$77.25
|
| Rate for Payer: United Healthcare Medicare |
$38.11
|
| Rate for Payer: WellCare Medicare |
$56.65
|
|
