|
AZITHROMYCIN 250MG TABS
|
Facility
|
OP
|
$16.50
|
|
|
Service Code
|
NDC 68180016006
|
| Hospital Charge Code |
4400088
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.61 |
| Max. Negotiated Rate |
$13.28 |
| Rate for Payer: Aetna of NY Commercial |
$11.55
|
| Rate for Payer: Aetna of NY Medicare |
$7.59
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$12.38
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$12.38
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$6.10
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$8.25
|
| Rate for Payer: Cash Price |
$12.38
|
| Rate for Payer: CDPHP Commercial |
$13.28
|
| Rate for Payer: CDPHP Medicare |
$6.10
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$13.20
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$13.20
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$13.20
|
| Rate for Payer: EmblemHealth Medicaid |
$13.20
|
| Rate for Payer: EmblemHealth Medicare |
$5.61
|
| Rate for Payer: EmblemHealth Select Care |
$11.88
|
| Rate for Payer: Fidelis Medicare |
$6.29
|
| Rate for Payer: Galaxy Health Commercial |
$10.72
|
| Rate for Payer: Hamaspik Choice Medicare |
$6.10
|
| Rate for Payer: Humana Medicare |
$6.10
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$11.55
|
| Rate for Payer: Local 1199SEIU Medicare |
$7.59
|
| Rate for Payer: MVP Health Care of NY Commercial |
$12.38
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$9.29
|
| Rate for Payer: MVP Health Care of NY Medicare |
$6.41
|
| Rate for Payer: United Healthcare Medicare |
$6.10
|
| Rate for Payer: WellCare Medicare |
$9.08
|
|
|
AZITHROMYCIN 250MG TABS
|
Facility
|
IP
|
$16.50
|
|
|
Service Code
|
NDC 68180016006
|
| Hospital Charge Code |
4400088
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.08 |
| Max. Negotiated Rate |
$10.72 |
| Rate for Payer: Cash Price |
$12.38
|
| Rate for Payer: Galaxy Health Commercial |
$10.72
|
| Rate for Payer: WellCare Medicare |
$9.08
|
|
|
AZITHROMYCIN 500 MG INJ
|
Facility
|
IP
|
$22.15
|
|
|
Service Code
|
HCPCS J0456
|
| Hospital Charge Code |
4400089
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.41 |
| Max. Negotiated Rate |
$14.40 |
| Rate for Payer: Aetna of NY Commercial |
$12.18
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$2.41
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$2.41
|
| Rate for Payer: Cash Price |
$16.61
|
| Rate for Payer: Cash Price |
$16.61
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$2.41
|
| Rate for Payer: EmblemHealth Select Care |
$2.41
|
| Rate for Payer: Galaxy Health Commercial |
$14.40
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$12.18
|
| Rate for Payer: WellCare Medicare |
$12.18
|
|
|
AZITHROMYCIN 500 MG INJ
|
Facility
|
OP
|
$22.15
|
|
|
Service Code
|
HCPCS J0456
|
| Hospital Charge Code |
4400089
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.41 |
| Max. Negotiated Rate |
$17.83 |
| Rate for Payer: Aetna of NY Commercial |
$12.18
|
| Rate for Payer: Aetna of NY Medicare |
$10.19
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$2.41
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$2.41
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$8.20
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$11.08
|
| Rate for Payer: Cash Price |
$16.61
|
| Rate for Payer: Cash Price |
$16.61
|
| Rate for Payer: CDPHP Commercial |
$17.83
|
| Rate for Payer: CDPHP Medicare |
$8.20
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$2.41
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$17.72
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$17.72
|
| Rate for Payer: EmblemHealth Medicaid |
$17.72
|
| Rate for Payer: EmblemHealth Medicare |
$7.53
|
| Rate for Payer: EmblemHealth Select Care |
$2.41
|
| Rate for Payer: Fidelis Medicare |
$8.44
|
| Rate for Payer: Galaxy Health Commercial |
$14.40
|
| Rate for Payer: Hamaspik Choice Medicare |
$8.20
|
| Rate for Payer: Humana Medicare |
$8.20
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$12.18
|
| Rate for Payer: Local 1199SEIU Medicare |
$10.19
|
| Rate for Payer: MVP Health Care of NY Commercial |
$16.61
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$12.47
|
| Rate for Payer: MVP Health Care of NY Medicare |
$8.61
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$4.59
|
| Rate for Payer: United Healthcare Commercial |
$4.59
|
| Rate for Payer: United Healthcare Medicare |
$8.20
|
| Rate for Payer: WellCare Medicare |
$12.18
|
|
|
BACITRACIN 50000 U
|
Facility
|
IP
|
$41.20
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
4400092
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.54 |
| Max. Negotiated Rate |
$26.78 |
| Rate for Payer: Aetna of NY Commercial |
$22.66
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$18.54
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$18.54
|
| Rate for Payer: Cash Price |
$30.90
|
| Rate for Payer: Galaxy Health Commercial |
$26.78
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$22.66
|
| Rate for Payer: WellCare Medicare |
$22.66
|
|
|
BACITRACIN 50000 U
|
Facility
|
OP
|
$41.20
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
4400092
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.01 |
| Max. Negotiated Rate |
$33.17 |
| Rate for Payer: Aetna of NY Commercial |
$22.66
|
| Rate for Payer: Aetna of NY Medicare |
$18.95
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$18.54
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$18.54
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$15.24
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$20.60
|
| Rate for Payer: Cash Price |
$30.90
|
| Rate for Payer: CDPHP Commercial |
$33.17
|
| Rate for Payer: CDPHP Medicare |
$15.24
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$32.96
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$32.96
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$32.96
|
| Rate for Payer: EmblemHealth Medicaid |
$32.96
|
| Rate for Payer: EmblemHealth Medicare |
$14.01
|
| Rate for Payer: EmblemHealth Select Care |
$29.66
|
| Rate for Payer: Fidelis Medicare |
$15.70
|
| Rate for Payer: Galaxy Health Commercial |
$26.78
|
| Rate for Payer: Hamaspik Choice Medicare |
$15.24
|
| Rate for Payer: Humana Medicare |
$15.24
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$22.66
|
| Rate for Payer: Local 1199SEIU Medicare |
$18.95
|
| Rate for Payer: MVP Health Care of NY Commercial |
$30.90
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$23.20
|
| Rate for Payer: MVP Health Care of NY Medicare |
$16.01
|
| Rate for Payer: United Healthcare Medicare |
$15.24
|
| Rate for Payer: WellCare Medicare |
$22.66
|
|
|
BACITRACIN/POLYMYXIN B 500-10000U/GM OIN
|
Facility
|
IP
|
$79.31
|
|
|
Service Code
|
NDC 17478023835
|
| Hospital Charge Code |
4400025
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$43.62 |
| Max. Negotiated Rate |
$51.55 |
| Rate for Payer: Cash Price |
$59.48
|
| Rate for Payer: Galaxy Health Commercial |
$51.55
|
| Rate for Payer: WellCare Medicare |
$43.62
|
|
|
BACITRACIN/POLYMYXIN B 500-10000U/GM OIN
|
Facility
|
OP
|
$79.31
|
|
|
Service Code
|
NDC 17478023835
|
| Hospital Charge Code |
4400025
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.97 |
| Max. Negotiated Rate |
$63.84 |
| Rate for Payer: Aetna of NY Commercial |
$55.52
|
| Rate for Payer: Aetna of NY Medicare |
$36.48
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$59.48
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$59.48
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$29.34
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$39.66
|
| Rate for Payer: Cash Price |
$59.48
|
| Rate for Payer: CDPHP Commercial |
$63.84
|
| Rate for Payer: CDPHP Medicare |
$29.34
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$63.45
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$63.45
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$63.45
|
| Rate for Payer: EmblemHealth Medicaid |
$63.45
|
| Rate for Payer: EmblemHealth Medicare |
$26.97
|
| Rate for Payer: EmblemHealth Select Care |
$57.10
|
| Rate for Payer: Fidelis Medicare |
$30.23
|
| Rate for Payer: Galaxy Health Commercial |
$51.55
|
| Rate for Payer: Hamaspik Choice Medicare |
$29.34
|
| Rate for Payer: Humana Medicare |
$29.34
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$55.52
|
| Rate for Payer: Local 1199SEIU Medicare |
$36.48
|
| Rate for Payer: MVP Health Care of NY Commercial |
$59.48
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$44.65
|
| Rate for Payer: MVP Health Care of NY Medicare |
$30.81
|
| Rate for Payer: United Healthcare Medicare |
$29.34
|
| Rate for Payer: WellCare Medicare |
$43.62
|
|
|
BACLOFEN 20MG TABS 10X10EA
|
Facility
|
OP
|
$6.18
|
|
|
Service Code
|
NDC 00904647661
|
| Hospital Charge Code |
4400095
|
|
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
|
|
|
BACLOFEN 20MG TABS 10X10EA
|
Facility
|
IP
|
$6.18
|
|
|
Service Code
|
NDC 00904647661
|
| Hospital Charge Code |
4400095
|
|
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
|
|
|
BACLOFEN 5 MG TABLET 5 mg, 100 eaches
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
NDC 52817031910
|
| Hospital Charge Code |
4401493
|
|
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
|
|
|
BACLOFEN 5 MG TABLET 5 mg, 100 eaches
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
NDC 52817031910
|
| Hospital Charge Code |
4401493
|
|
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
|
|
|
BACTERIAL CULTURE
|
Facility
|
OP
|
$34.00
|
|
|
Service Code
|
HCPCS 87070
|
| Hospital Charge Code |
4300109
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$8.23 |
| Max. Negotiated Rate |
$27.37 |
| Rate for Payer: Aetna of NY Commercial |
$22.10
|
| Rate for Payer: Aetna of NY Medicare |
$15.64
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$25.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$25.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$12.58
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$17.00
|
| Rate for Payer: Cash Price |
$25.50
|
| Rate for Payer: Cash Price |
$25.50
|
| Rate for Payer: CDPHP Commercial |
$27.37
|
| Rate for Payer: CDPHP Medicare |
$12.58
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$20.40
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$27.20
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$27.20
|
| Rate for Payer: EmblemHealth Medicaid |
$27.20
|
| Rate for Payer: EmblemHealth Medicare |
$11.56
|
| Rate for Payer: EmblemHealth Select Care |
$20.40
|
| Rate for Payer: Fidelis Medicare |
$12.96
|
| Rate for Payer: Galaxy Health Commercial |
$22.10
|
| Rate for Payer: Hamaspik Choice Medicare |
$12.58
|
| Rate for Payer: Humana Medicare |
$12.58
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$22.10
|
| Rate for Payer: Local 1199SEIU Medicare |
$15.64
|
| Rate for Payer: MVP Health Care of NY Commercial |
$25.50
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$19.14
|
| Rate for Payer: MVP Health Care of NY Medicare |
$13.21
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$25.50
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$8.23
|
| Rate for Payer: United Healthcare Commercial |
$25.50
|
| Rate for Payer: United Healthcare Medicare |
$12.58
|
| Rate for Payer: WellCare Medicare |
$18.70
|
|
|
BACTERIAL CULTURE
|
Facility
|
IP
|
$34.00
|
|
|
Service Code
|
HCPCS 87070
|
| Hospital Charge Code |
4300109
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$22.10 |
| Max. Negotiated Rate |
$22.10 |
| Rate for Payer: Cash Price |
$25.50
|
| Rate for Payer: Galaxy Health Commercial |
$22.10
|
|
|
BACTERIAL ID
|
Facility
|
OP
|
$32.00
|
|
|
Service Code
|
HCPCS 87077
|
| Hospital Charge Code |
4301088
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.08 |
| Max. Negotiated Rate |
$25.76 |
| Rate for Payer: Aetna of NY Commercial |
$20.80
|
| Rate for Payer: Aetna of NY Medicare |
$14.72
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$24.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$24.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$11.84
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$16.00
|
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: CDPHP Commercial |
$25.76
|
| Rate for Payer: CDPHP Medicare |
$11.84
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$19.20
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$25.60
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$25.60
|
| Rate for Payer: EmblemHealth Medicaid |
$25.60
|
| Rate for Payer: EmblemHealth Medicare |
$10.88
|
| Rate for Payer: EmblemHealth Select Care |
$19.20
|
| Rate for Payer: Fidelis Medicare |
$12.20
|
| Rate for Payer: Galaxy Health Commercial |
$20.80
|
| Rate for Payer: Hamaspik Choice Medicare |
$11.84
|
| Rate for Payer: Humana Medicare |
$11.84
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$20.80
|
| Rate for Payer: Local 1199SEIU Medicare |
$14.72
|
| Rate for Payer: MVP Health Care of NY Commercial |
$24.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$18.02
|
| Rate for Payer: MVP Health Care of NY Medicare |
$12.43
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$24.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$8.08
|
| Rate for Payer: United Healthcare Commercial |
$24.00
|
| Rate for Payer: United Healthcare Medicare |
$11.84
|
| Rate for Payer: WellCare Medicare |
$17.60
|
|
|
BACTERIAL ID
|
Facility
|
IP
|
$32.00
|
|
|
Service Code
|
HCPCS 87077
|
| Hospital Charge Code |
4301088
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$20.80 |
| Max. Negotiated Rate |
$20.80 |
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: Galaxy Health Commercial |
$20.80
|
|
|
BALANCE B-50 TABLET 1 ea, 1 each
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
NDC 50268085715
|
| Hospital Charge Code |
4401327
|
|
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
|
|
|
BALANCE B-50 TABLET 1 ea, 1 each
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
NDC 50268085715
|
| Hospital Charge Code |
4401327
|
|
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
|
|
|
BARRIER SKIN 1 1/2 FLEX COST BOX
|
Facility
|
IP
|
$22.00
|
|
| Hospital Charge Code |
4479129
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$14.30 |
| Max. Negotiated Rate |
$14.30 |
| Rate for Payer: Cash Price |
$16.50
|
| Rate for Payer: Galaxy Health Commercial |
$14.30
|
|
|
BARRIER SKIN 1 1/2 FLEX COST BOX
|
Facility
|
OP
|
$22.00
|
|
| Hospital Charge Code |
4479129
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$7.48 |
| Max. Negotiated Rate |
$17.71 |
| Rate for Payer: Aetna of NY Commercial |
$15.40
|
| Rate for Payer: Aetna of NY Medicare |
$10.12
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$16.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$16.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$8.14
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$11.00
|
| Rate for Payer: Cash Price |
$16.50
|
| Rate for Payer: CDPHP Commercial |
$17.71
|
| Rate for Payer: CDPHP Medicare |
$8.14
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$17.60
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$17.60
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$17.60
|
| Rate for Payer: EmblemHealth Medicaid |
$17.60
|
| Rate for Payer: EmblemHealth Medicare |
$7.48
|
| Rate for Payer: EmblemHealth Select Care |
$15.84
|
| Rate for Payer: Fidelis Medicare |
$8.38
|
| Rate for Payer: Galaxy Health Commercial |
$14.30
|
| Rate for Payer: Hamaspik Choice Medicare |
$8.14
|
| Rate for Payer: Humana Medicare |
$8.14
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$15.40
|
| Rate for Payer: Local 1199SEIU Medicare |
$10.12
|
| Rate for Payer: MVP Health Care of NY Commercial |
$16.50
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$12.39
|
| Rate for Payer: MVP Health Care of NY Medicare |
$8.55
|
| Rate for Payer: United Healthcare Medicare |
$8.14
|
| Rate for Payer: WellCare Medicare |
$12.10
|
|
|
BARRIER SKIN 11/4 FLEX
|
Facility
|
OP
|
$22.00
|
|
| Hospital Charge Code |
4479128
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$7.48 |
| Max. Negotiated Rate |
$17.71 |
| Rate for Payer: Aetna of NY Commercial |
$15.40
|
| Rate for Payer: Aetna of NY Medicare |
$10.12
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$16.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$16.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$8.14
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$11.00
|
| Rate for Payer: Cash Price |
$16.50
|
| Rate for Payer: CDPHP Commercial |
$17.71
|
| Rate for Payer: CDPHP Medicare |
$8.14
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$17.60
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$17.60
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$17.60
|
| Rate for Payer: EmblemHealth Medicaid |
$17.60
|
| Rate for Payer: EmblemHealth Medicare |
$7.48
|
| Rate for Payer: EmblemHealth Select Care |
$15.84
|
| Rate for Payer: Fidelis Medicare |
$8.38
|
| Rate for Payer: Galaxy Health Commercial |
$14.30
|
| Rate for Payer: Hamaspik Choice Medicare |
$8.14
|
| Rate for Payer: Humana Medicare |
$8.14
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$15.40
|
| Rate for Payer: Local 1199SEIU Medicare |
$10.12
|
| Rate for Payer: MVP Health Care of NY Commercial |
$16.50
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$12.39
|
| Rate for Payer: MVP Health Care of NY Medicare |
$8.55
|
| Rate for Payer: United Healthcare Medicare |
$8.14
|
| Rate for Payer: WellCare Medicare |
$12.10
|
|
|
BARRIER SKIN 11/4 FLEX
|
Facility
|
IP
|
$22.00
|
|
| Hospital Charge Code |
4479128
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$14.30 |
| Max. Negotiated Rate |
$14.30 |
| Rate for Payer: Cash Price |
$16.50
|
| Rate for Payer: Galaxy Health Commercial |
$14.30
|
|
|
BARRIER SKIN 2 1/4 FLEX COST BOX
|
Facility
|
OP
|
$27.00
|
|
| Hospital Charge Code |
4479130
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$9.18 |
| Max. Negotiated Rate |
$21.74 |
| Rate for Payer: Aetna of NY Commercial |
$18.90
|
| Rate for Payer: Aetna of NY Medicare |
$12.42
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$20.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$20.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$9.99
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$13.50
|
| Rate for Payer: Cash Price |
$20.25
|
| Rate for Payer: CDPHP Commercial |
$21.74
|
| Rate for Payer: CDPHP Medicare |
$9.99
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$21.60
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$21.60
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$21.60
|
| Rate for Payer: EmblemHealth Medicaid |
$21.60
|
| Rate for Payer: EmblemHealth Medicare |
$9.18
|
| Rate for Payer: EmblemHealth Select Care |
$19.44
|
| Rate for Payer: Fidelis Medicare |
$10.29
|
| Rate for Payer: Galaxy Health Commercial |
$17.55
|
| Rate for Payer: Hamaspik Choice Medicare |
$9.99
|
| Rate for Payer: Humana Medicare |
$9.99
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$18.90
|
| Rate for Payer: Local 1199SEIU Medicare |
$12.42
|
| Rate for Payer: MVP Health Care of NY Commercial |
$20.25
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$15.20
|
| Rate for Payer: MVP Health Care of NY Medicare |
$10.49
|
| Rate for Payer: United Healthcare Medicare |
$9.99
|
| Rate for Payer: WellCare Medicare |
$14.85
|
|
|
BARRIER SKIN 2 1/4 FLEX COST BOX
|
Facility
|
IP
|
$27.00
|
|
| Hospital Charge Code |
4479130
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$17.55 |
| Max. Negotiated Rate |
$17.55 |
| Rate for Payer: Cash Price |
$20.25
|
| Rate for Payer: Galaxy Health Commercial |
$17.55
|
|
|
BARRIER SKIN 2 3/4 FLEX COST BOX 10
|
Facility
|
IP
|
$27.00
|
|
| Hospital Charge Code |
4479131
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$17.55 |
| Max. Negotiated Rate |
$17.55 |
| Rate for Payer: Cash Price |
$20.25
|
| Rate for Payer: Galaxy Health Commercial |
$17.55
|
|
