|
AUTOMATED PLATELET COUNT
|
Facility
|
IP
|
$13.00
|
|
|
Service Code
|
HCPCS 85049
|
| Hospital Charge Code |
4301424
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$8.45 |
| Max. Negotiated Rate |
$8.45 |
| Rate for Payer: Cash Price |
$9.75
|
| Rate for Payer: Galaxy Health Commercial |
$8.45
|
|
|
AUTOMATED PLATELET COUNT
|
Facility
|
OP
|
$13.00
|
|
|
Service Code
|
HCPCS 85049
|
| Hospital Charge Code |
4301424
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$1.95 |
| Max. Negotiated Rate |
$10.40 |
| Rate for Payer: Aetna of NY Commercial |
$8.45
|
| Rate for Payer: Aetna of NY Medicare |
$5.98
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$5.20
|
| Rate for Payer: Cash Price |
$9.75
|
| Rate for Payer: CDPHP Medicare |
$4.81
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$7.80
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$10.40
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$10.40
|
| Rate for Payer: EmblemHealth Medicaid |
$10.40
|
| Rate for Payer: EmblemHealth Medicare |
$4.42
|
| Rate for Payer: EmblemHealth Select Care |
$7.80
|
| Rate for Payer: Fidelis Medicare |
$5.20
|
| Rate for Payer: Galaxy Health Commercial |
$8.45
|
| Rate for Payer: Hamaspik Choice Medicare |
$5.20
|
| Rate for Payer: Humana Medicare |
$5.20
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$8.45
|
| Rate for Payer: Local 1199SEIU Medicare |
$5.98
|
| Rate for Payer: MVP Health Care of NY Commercial |
$9.75
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$7.32
|
| Rate for Payer: MVP Health Care of NY Medicare |
$5.46
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$9.75
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$1.95
|
| Rate for Payer: United Healthcare Commercial |
$9.75
|
| Rate for Payer: United Healthcare Medicare |
$5.20
|
| Rate for Payer: WellCare Medicare |
$7.15
|
|
|
AUTOM URINE DIP W MICRO
|
Facility
|
OP
|
$17.00
|
|
|
Service Code
|
HCPCS 81001
|
| Hospital Charge Code |
4300802
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$13.60 |
| Rate for Payer: Aetna of NY Commercial |
$11.05
|
| Rate for Payer: Aetna of NY Medicare |
$7.82
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$6.80
|
| Rate for Payer: Cash Price |
$12.75
|
| Rate for Payer: CDPHP Medicare |
$6.29
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$10.20
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$13.60
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$13.60
|
| Rate for Payer: EmblemHealth Medicaid |
$13.60
|
| Rate for Payer: EmblemHealth Medicare |
$5.78
|
| Rate for Payer: EmblemHealth Select Care |
$10.20
|
| Rate for Payer: Fidelis Medicare |
$6.80
|
| Rate for Payer: Galaxy Health Commercial |
$11.05
|
| Rate for Payer: Hamaspik Choice Medicare |
$6.80
|
| Rate for Payer: Humana Medicare |
$6.80
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$11.05
|
| Rate for Payer: Local 1199SEIU Medicare |
$7.82
|
| Rate for Payer: MVP Health Care of NY Commercial |
$12.75
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$9.57
|
| Rate for Payer: MVP Health Care of NY Medicare |
$7.14
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$12.75
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$2.55
|
| Rate for Payer: United Healthcare Commercial |
$12.75
|
| Rate for Payer: United Healthcare Medicare |
$6.80
|
| Rate for Payer: WellCare Medicare |
$9.35
|
|
|
AUTOM URINE DIP W MICRO
|
Facility
|
IP
|
$17.00
|
|
|
Service Code
|
HCPCS 81001
|
| Hospital Charge Code |
4300802
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.05 |
| Max. Negotiated Rate |
$11.05 |
| Rate for Payer: Cash Price |
$12.75
|
| Rate for Payer: Galaxy Health Commercial |
$11.05
|
|
|
AUTOSUTURE ROYAL 35W SKIN STAPLER
|
Facility
|
IP
|
$73.13
|
|
| Hospital Charge Code |
4472212
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$47.53 |
| Max. Negotiated Rate |
$47.53 |
| Rate for Payer: Cash Price |
$54.85
|
| Rate for Payer: Galaxy Health Commercial |
$47.53
|
|
|
AUTOSUTURE ROYAL 35W SKIN STAPLER
|
Facility
|
OP
|
$73.13
|
|
| Hospital Charge Code |
4472212
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$10.97 |
| Max. Negotiated Rate |
$58.50 |
| Rate for Payer: Aetna of NY Commercial |
$51.19
|
| Rate for Payer: Aetna of NY Medicare |
$33.64
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$29.25
|
| Rate for Payer: Cash Price |
$54.85
|
| Rate for Payer: CDPHP Medicare |
$27.06
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$58.50
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$58.50
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$58.50
|
| Rate for Payer: EmblemHealth Medicaid |
$58.50
|
| Rate for Payer: EmblemHealth Medicare |
$24.86
|
| Rate for Payer: EmblemHealth Select Care |
$52.65
|
| Rate for Payer: Fidelis Medicare |
$29.25
|
| Rate for Payer: Galaxy Health Commercial |
$47.53
|
| Rate for Payer: Hamaspik Choice Medicare |
$29.25
|
| Rate for Payer: Humana Medicare |
$29.25
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$51.19
|
| Rate for Payer: Local 1199SEIU Medicare |
$33.64
|
| Rate for Payer: MVP Health Care of NY Commercial |
$54.85
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$41.17
|
| Rate for Payer: MVP Health Care of NY Medicare |
$30.71
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$10.97
|
| Rate for Payer: United Healthcare Medicare |
$29.25
|
| Rate for Payer: WellCare Medicare |
$40.22
|
|
|
AVAMAX BONE CEMENT DELIVERY SYS VMX00CT
|
Facility
|
IP
|
$2,802.63
|
|
| Hospital Charge Code |
4479294
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$1,821.71 |
| Max. Negotiated Rate |
$1,821.71 |
| Rate for Payer: Cash Price |
$2,101.97
|
| Rate for Payer: Galaxy Health Commercial |
$1,821.71
|
|
|
AVAMAX BONE CEMENT DELIVERY SYS VMX00CT
|
Facility
|
OP
|
$2,802.63
|
|
| Hospital Charge Code |
4479294
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$420.39 |
| Max. Negotiated Rate |
$2,242.10 |
| Rate for Payer: Aetna of NY Commercial |
$1,961.84
|
| Rate for Payer: Aetna of NY Medicare |
$1,289.21
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$1,121.05
|
| Rate for Payer: Cash Price |
$2,101.97
|
| Rate for Payer: CDPHP Medicare |
$1,036.97
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$2,242.10
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$2,242.10
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$2,242.10
|
| Rate for Payer: EmblemHealth Medicaid |
$2,242.10
|
| Rate for Payer: EmblemHealth Medicare |
$952.89
|
| Rate for Payer: EmblemHealth Select Care |
$2,017.89
|
| Rate for Payer: Fidelis Medicare |
$1,121.05
|
| Rate for Payer: Galaxy Health Commercial |
$1,821.71
|
| Rate for Payer: Hamaspik Choice Medicare |
$1,121.05
|
| Rate for Payer: Humana Medicare |
$1,121.05
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,961.84
|
| Rate for Payer: Local 1199SEIU Medicare |
$1,289.21
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,101.97
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$1,577.88
|
| Rate for Payer: MVP Health Care of NY Medicare |
$1,177.10
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$420.39
|
| Rate for Payer: United Healthcare Medicare |
$1,121.05
|
| Rate for Payer: WellCare Medicare |
$1,541.45
|
|
|
AVISTA MRI LEAD - 56CM/74CM
|
Facility
|
IP
|
$15,268.72
|
|
|
Service Code
|
HCPCS C1778
|
| Hospital Charge Code |
4479094
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,870.92 |
| Max. Negotiated Rate |
$10,688.10 |
| Rate for Payer: Aetna of NY Commercial |
$10,688.10
|
| Rate for Payer: Cash Price |
$11,451.54
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$7,634.36
|
| Rate for Payer: EmblemHealth Select Care |
$7,634.36
|
| Rate for Payer: Galaxy Health Commercial |
$9,924.67
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$10,688.10
|
| Rate for Payer: Multiplan Commercial |
$6,870.92
|
| Rate for Payer: MVP Health Care of NY Commercial |
$9,924.67
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$9,924.67
|
| Rate for Payer: WellCare Medicare |
$8,397.80
|
|
|
AVISTA MRI LEAD - 56CM/74CM
|
Facility
|
OP
|
$15,268.72
|
|
|
Service Code
|
HCPCS C1778
|
| Hospital Charge Code |
4479094
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,290.31 |
| Max. Negotiated Rate |
$12,214.98 |
| Rate for Payer: Aetna of NY Commercial |
$10,688.10
|
| Rate for Payer: Aetna of NY Medicare |
$7,023.61
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$6,107.49
|
| Rate for Payer: Cash Price |
$11,451.54
|
| Rate for Payer: CDPHP Medicare |
$5,649.43
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$7,634.36
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$12,214.98
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$12,214.98
|
| Rate for Payer: EmblemHealth Medicaid |
$12,214.98
|
| Rate for Payer: EmblemHealth Medicare |
$5,191.36
|
| Rate for Payer: EmblemHealth Select Care |
$7,634.36
|
| Rate for Payer: Fidelis Medicare |
$6,107.49
|
| Rate for Payer: Galaxy Health Commercial |
$9,924.67
|
| Rate for Payer: Hamaspik Choice Medicare |
$6,107.49
|
| Rate for Payer: Humana Medicare |
$6,107.49
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$10,688.10
|
| Rate for Payer: Local 1199SEIU Medicare |
$7,023.61
|
| Rate for Payer: MVP Health Care of NY Commercial |
$9,924.67
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$9,924.67
|
| Rate for Payer: MVP Health Care of NY Medicare |
$6,412.86
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$2,290.31
|
| Rate for Payer: United Healthcare Medicare |
$6,107.49
|
| Rate for Payer: WellCare Medicare |
$8,397.80
|
|
|
AVULSION OF NAIL PLATE,SIMPLE, SINGLE
|
Facility
|
IP
|
$615.00
|
|
|
Service Code
|
HCPCS 11730
|
| Hospital Charge Code |
4856671
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$399.75 |
| Max. Negotiated Rate |
$399.75 |
| Rate for Payer: Cash Price |
$461.25
|
| Rate for Payer: Galaxy Health Commercial |
$399.75
|
|
|
AVULSION OF NAIL PLATE,SIMPLE, SINGLE
|
Facility
|
OP
|
$615.00
|
|
|
Service Code
|
HCPCS 11730
|
| Hospital Charge Code |
4856671
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$92.25 |
| Max. Negotiated Rate |
$492.00 |
| Rate for Payer: Aetna of NY Commercial |
$430.50
|
| Rate for Payer: Aetna of NY Medicare |
$282.90
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$246.00
|
| Rate for Payer: Cash Price |
$461.25
|
| Rate for Payer: CDPHP Medicare |
$227.55
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$492.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$492.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$492.00
|
| Rate for Payer: EmblemHealth Medicaid |
$492.00
|
| Rate for Payer: EmblemHealth Medicare |
$209.10
|
| Rate for Payer: EmblemHealth Select Care |
$442.80
|
| Rate for Payer: Fidelis Medicare |
$246.00
|
| Rate for Payer: Galaxy Health Commercial |
$399.75
|
| Rate for Payer: Hamaspik Choice Medicare |
$246.00
|
| Rate for Payer: Humana Medicare |
$246.00
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$430.50
|
| Rate for Payer: Local 1199SEIU Medicare |
$282.90
|
| Rate for Payer: MVP Health Care of NY Commercial |
$461.25
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$346.25
|
| Rate for Payer: MVP Health Care of NY Medicare |
$258.30
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$92.25
|
| Rate for Payer: United Healthcare Medicare |
$246.00
|
| Rate for Payer: WellCare Medicare |
$338.25
|
|
|
AZACTAM 1 GRAM INJECTION
|
Facility
|
IP
|
$107.64
|
|
|
Service Code
|
NDC 3256016
|
| Hospital Charge Code |
4409087
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$69.97 |
| Max. Negotiated Rate |
$69.97 |
| Rate for Payer: Cash Price |
$80.73
|
| Rate for Payer: Galaxy Health Commercial |
$69.97
|
|
|
AZACTAM 1 GRAM INJECTION
|
Facility
|
OP
|
$107.64
|
|
|
Service Code
|
NDC 3256016
|
| Hospital Charge Code |
4409087
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$16.15 |
| Max. Negotiated Rate |
$86.11 |
| Rate for Payer: Aetna of NY Commercial |
$75.35
|
| Rate for Payer: Aetna of NY Medicare |
$49.51
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$43.06
|
| Rate for Payer: Cash Price |
$80.73
|
| Rate for Payer: CDPHP Medicare |
$39.83
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$86.11
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$86.11
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$86.11
|
| Rate for Payer: EmblemHealth Medicaid |
$86.11
|
| Rate for Payer: EmblemHealth Medicare |
$36.60
|
| Rate for Payer: EmblemHealth Select Care |
$77.50
|
| Rate for Payer: Fidelis Medicare |
$43.06
|
| Rate for Payer: Galaxy Health Commercial |
$69.97
|
| Rate for Payer: Hamaspik Choice Medicare |
$43.06
|
| Rate for Payer: Humana Medicare |
$43.06
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$75.35
|
| Rate for Payer: Local 1199SEIU Medicare |
$49.51
|
| Rate for Payer: MVP Health Care of NY Commercial |
$80.73
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$60.60
|
| Rate for Payer: MVP Health Care of NY Medicare |
$45.21
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$16.15
|
| Rate for Payer: United Healthcare Medicare |
$43.06
|
| Rate for Payer: WellCare Medicare |
$59.20
|
|
|
AZACTAM (AZTREONAM) INJECTION 2 GRAMS
|
Facility
|
IP
|
$215.01
|
|
|
Service Code
|
NDC 3257016
|
| Hospital Charge Code |
4409219
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$118.26 |
| Max. Negotiated Rate |
$139.76 |
| Rate for Payer: Cash Price |
$161.26
|
| Rate for Payer: Galaxy Health Commercial |
$139.76
|
| Rate for Payer: WellCare Medicare |
$118.26
|
|
|
AZACTAM (AZTREONAM) INJECTION 2 GRAMS
|
Facility
|
OP
|
$215.01
|
|
|
Service Code
|
NDC 3257016
|
| Hospital Charge Code |
4409219
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$32.25 |
| Max. Negotiated Rate |
$172.01 |
| Rate for Payer: Aetna of NY Commercial |
$150.51
|
| Rate for Payer: Aetna of NY Medicare |
$98.90
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$86.00
|
| Rate for Payer: Cash Price |
$161.26
|
| Rate for Payer: CDPHP Medicare |
$79.55
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$172.01
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$172.01
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$172.01
|
| Rate for Payer: EmblemHealth Medicaid |
$172.01
|
| Rate for Payer: EmblemHealth Medicare |
$73.10
|
| Rate for Payer: EmblemHealth Select Care |
$154.81
|
| Rate for Payer: Fidelis Medicare |
$86.00
|
| Rate for Payer: Galaxy Health Commercial |
$139.76
|
| Rate for Payer: Hamaspik Choice Medicare |
$86.00
|
| Rate for Payer: Humana Medicare |
$86.00
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$150.51
|
| Rate for Payer: Local 1199SEIU Medicare |
$98.90
|
| Rate for Payer: MVP Health Care of NY Commercial |
$161.26
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$121.05
|
| Rate for Payer: MVP Health Care of NY Medicare |
$90.30
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$32.25
|
| Rate for Payer: United Healthcare Medicare |
$86.00
|
| Rate for Payer: WellCare Medicare |
$118.26
|
|
|
AZITHROMYCIN 100MG/5ML POSR 15 ML
|
Facility
|
OP
|
$104.64
|
|
|
Service Code
|
NDC 93202723
|
| Hospital Charge Code |
4400087
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.70 |
| Max. Negotiated Rate |
$83.71 |
| Rate for Payer: Aetna of NY Commercial |
$73.25
|
| Rate for Payer: Aetna of NY Medicare |
$48.13
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$41.86
|
| Rate for Payer: Cash Price |
$78.48
|
| Rate for Payer: CDPHP Medicare |
$38.72
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$83.71
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$83.71
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$83.71
|
| Rate for Payer: EmblemHealth Medicaid |
$83.71
|
| Rate for Payer: EmblemHealth Medicare |
$35.58
|
| Rate for Payer: EmblemHealth Select Care |
$75.34
|
| Rate for Payer: Fidelis Medicare |
$41.86
|
| Rate for Payer: Galaxy Health Commercial |
$68.02
|
| Rate for Payer: Hamaspik Choice Medicare |
$41.86
|
| Rate for Payer: Humana Medicare |
$41.86
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$73.25
|
| Rate for Payer: Local 1199SEIU Medicare |
$48.13
|
| Rate for Payer: MVP Health Care of NY Commercial |
$78.48
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$58.91
|
| Rate for Payer: MVP Health Care of NY Medicare |
$43.95
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$15.70
|
| Rate for Payer: United Healthcare Medicare |
$41.86
|
| Rate for Payer: WellCare Medicare |
$57.55
|
|
|
AZITHROMYCIN 100MG/5ML POSR 15 ML
|
Facility
|
IP
|
$104.64
|
|
|
Service Code
|
NDC 93202723
|
| Hospital Charge Code |
4400087
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$57.55 |
| Max. Negotiated Rate |
$68.02 |
| Rate for Payer: Cash Price |
$78.48
|
| Rate for Payer: Galaxy Health Commercial |
$68.02
|
| Rate for Payer: WellCare Medicare |
$57.55
|
|
|
AZITHROMYCIN 250MG TABS
|
Facility
|
OP
|
$16.50
|
|
|
Service Code
|
NDC 68180016006
|
| Hospital Charge Code |
4400088
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.48 |
| Max. Negotiated Rate |
$13.20 |
| 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) Medicare |
$6.60
|
| Rate for Payer: Cash Price |
$12.38
|
| Rate for Payer: CDPHP Medicare |
$6.11
|
| 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 |
$6.60
|
| Rate for Payer: Galaxy Health Commercial |
$10.72
|
| Rate for Payer: Hamaspik Choice Medicare |
$6.60
|
| Rate for Payer: Humana Medicare |
$6.60
|
| 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 |
$6.93
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$2.48
|
| Rate for Payer: United Healthcare Medicare |
$6.60
|
| Rate for Payer: WellCare Medicare |
$9.07
|
|
|
AZITHROMYCIN 250MG TABS
|
Facility
|
IP
|
$16.50
|
|
|
Service Code
|
NDC 68180016006
|
| Hospital Charge Code |
4400088
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.07 |
| 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 |
$9.07
|
|
|
AZITHROMYCIN 500 MG INJ
|
Facility
|
IP
|
$22.15
|
|
|
Service Code
|
HCPCS J0456
|
| Hospital Charge Code |
4400089
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.94 |
| Max. Negotiated Rate |
$14.40 |
| Rate for Payer: Aetna of NY Commercial |
$12.18
|
| Rate for Payer: Cash Price |
$16.61
|
| Rate for Payer: Cash Price |
$16.61
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$1.94
|
| Rate for Payer: EmblemHealth Select Care |
$1.94
|
| 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 |
$1.94 |
| Max. Negotiated Rate |
$17.72 |
| Rate for Payer: Aetna of NY Medicare |
$10.19
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$8.86
|
| Rate for Payer: Cash Price |
$16.61
|
| Rate for Payer: Cash Price |
$16.61
|
| Rate for Payer: CDPHP Medicare |
$8.20
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$1.94
|
| 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 |
$1.94
|
| Rate for Payer: Fidelis Medicare |
$8.86
|
| Rate for Payer: Galaxy Health Commercial |
$14.40
|
| Rate for Payer: Hamaspik Choice Medicare |
$8.86
|
| Rate for Payer: Humana Medicare |
$8.86
|
| 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 |
$9.30
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$4.59
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$3.32
|
| Rate for Payer: United Healthcare Commercial |
$4.59
|
| Rate for Payer: United Healthcare Medicare |
$8.86
|
| Rate for Payer: WellCare Medicare |
$12.18
|
|
|
BACITRACIN 50000 U
|
Facility
|
OP
|
$41.20
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
4400092
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.18 |
| Max. Negotiated Rate |
$32.96 |
| Rate for Payer: Aetna of NY Medicare |
$18.95
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$16.48
|
| Rate for Payer: Cash Price |
$30.90
|
| 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 |
$16.48
|
| Rate for Payer: Galaxy Health Commercial |
$26.78
|
| Rate for Payer: Hamaspik Choice Medicare |
$16.48
|
| Rate for Payer: Humana Medicare |
$16.48
|
| 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 |
$17.30
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$6.18
|
| Rate for Payer: United Healthcare Medicare |
$16.48
|
| Rate for Payer: WellCare Medicare |
$22.66
|
|
|
BACITRACIN 50000 U
|
Facility
|
IP
|
$41.20
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
4400092
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.66 |
| Max. Negotiated Rate |
$26.78 |
| Rate for Payer: Aetna of NY Commercial |
$22.66
|
| 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/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
|
|
