|
BUPIVACAINE HCL 5MG/ML MDV 50 ML
|
Facility
|
IP
|
$6.18
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
4400484
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.78 |
| Max. Negotiated Rate |
$4.02 |
| Rate for Payer: Aetna of NY Commercial |
$3.40
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$2.78
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$2.78
|
| Rate for Payer: Cash Price |
$4.64
|
| Rate for Payer: Galaxy Health Commercial |
$4.02
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$3.40
|
| Rate for Payer: WellCare Medicare |
$3.40
|
|
|
BUPIVACAINE HCL 5MG/ML MDV 50 ML
|
Facility
|
OP
|
$6.18
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
4400484
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.10 |
| Max. Negotiated Rate |
$4.97 |
| Rate for Payer: Aetna of NY Commercial |
$3.40
|
| Rate for Payer: Aetna of NY Medicare |
$2.84
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$2.78
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$2.78
|
| 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 |
$3.40
|
| 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
|
|
|
BUPRENOR-NALOX 12-3 MG SL FILM 1 mg, 30 eaches
|
Facility
|
IP
|
$53.00
|
|
|
Service Code
|
HCPCS J0575
|
| Hospital Charge Code |
4401471
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.85 |
| Max. Negotiated Rate |
$34.45 |
| Rate for Payer: Aetna of NY Commercial |
$29.15
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$23.85
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$23.85
|
| Rate for Payer: Cash Price |
$39.75
|
| Rate for Payer: Galaxy Health Commercial |
$34.45
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$29.15
|
| Rate for Payer: WellCare Medicare |
$29.15
|
|
|
BUPRENOR-NALOX 12-3 MG SL FILM 1 mg, 30 eaches
|
Facility
|
OP
|
$53.00
|
|
|
Service Code
|
HCPCS J0575
|
| Hospital Charge Code |
4401471
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.02 |
| Max. Negotiated Rate |
$42.66 |
| Rate for Payer: Aetna of NY Commercial |
$29.15
|
| Rate for Payer: Aetna of NY Medicare |
$24.38
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$23.85
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$23.85
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$19.61
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$26.50
|
| Rate for Payer: Cash Price |
$39.75
|
| Rate for Payer: Cash Price |
$39.75
|
| Rate for Payer: CDPHP Commercial |
$42.66
|
| Rate for Payer: CDPHP Medicare |
$19.61
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$42.40
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$42.40
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$42.40
|
| Rate for Payer: EmblemHealth Medicaid |
$42.40
|
| Rate for Payer: EmblemHealth Medicare |
$18.02
|
| Rate for Payer: EmblemHealth Select Care |
$38.16
|
| Rate for Payer: Fidelis Medicare |
$20.20
|
| Rate for Payer: Galaxy Health Commercial |
$34.45
|
| Rate for Payer: Hamaspik Choice Medicare |
$19.61
|
| Rate for Payer: Humana Medicare |
$19.61
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$29.15
|
| Rate for Payer: Local 1199SEIU Medicare |
$24.38
|
| Rate for Payer: MVP Health Care of NY Commercial |
$39.75
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$29.84
|
| Rate for Payer: MVP Health Care of NY Medicare |
$20.59
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$30.18
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$18.39
|
| Rate for Payer: United Healthcare Commercial |
$30.18
|
| Rate for Payer: United Healthcare Medicare |
$19.61
|
| Rate for Payer: WellCare Medicare |
$29.15
|
|
|
BUPRENORPHINE-NALOX 4-1MG FILM 4 mg, 1 each
|
Facility
|
IP
|
$16.00
|
|
|
Service Code
|
NDC 47781035611
|
| Hospital Charge Code |
4401480
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.80 |
| Max. Negotiated Rate |
$10.40 |
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Galaxy Health Commercial |
$10.40
|
| Rate for Payer: WellCare Medicare |
$8.80
|
|
|
BUPRENORPHINE-NALOX 4-1MG FILM 4 mg, 1 each
|
Facility
|
OP
|
$16.00
|
|
|
Service Code
|
NDC 47781035611
|
| Hospital Charge Code |
4401480
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.44 |
| Max. Negotiated Rate |
$12.88 |
| Rate for Payer: Aetna of NY Commercial |
$11.20
|
| Rate for Payer: Aetna of NY Medicare |
$7.36
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$12.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$12.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$5.92
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$8.00
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: CDPHP Commercial |
$12.88
|
| Rate for Payer: CDPHP Medicare |
$5.92
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$12.80
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$12.80
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$12.80
|
| Rate for Payer: EmblemHealth Medicaid |
$12.80
|
| Rate for Payer: EmblemHealth Medicare |
$5.44
|
| Rate for Payer: EmblemHealth Select Care |
$11.52
|
| Rate for Payer: Fidelis Medicare |
$6.10
|
| Rate for Payer: Galaxy Health Commercial |
$10.40
|
| Rate for Payer: Hamaspik Choice Medicare |
$5.92
|
| Rate for Payer: Humana Medicare |
$5.92
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$11.20
|
| Rate for Payer: Local 1199SEIU Medicare |
$7.36
|
| Rate for Payer: MVP Health Care of NY Commercial |
$12.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$9.01
|
| Rate for Payer: MVP Health Care of NY Medicare |
$6.22
|
| Rate for Payer: United Healthcare Medicare |
$5.92
|
| Rate for Payer: WellCare Medicare |
$8.80
|
|
|
BUPRENORPHINE-NALOX 8-2MG FILM 8 ea, 30 eaches
|
Facility
|
OP
|
$14.00
|
|
|
Service Code
|
HCPCS J0574
|
| Hospital Charge Code |
4401490
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.76 |
| Max. Negotiated Rate |
$708.00 |
| Rate for Payer: Aetna of NY Commercial |
$7.70
|
| Rate for Payer: Aetna of NY Medicare |
$6.44
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$6.30
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$6.30
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Essential Plan |
$15.93
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicaid |
$7.08
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$5.18
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$7.00
|
| Rate for Payer: Cash Price |
$10.50
|
| Rate for Payer: Cash Price |
$10.50
|
| Rate for Payer: CDPHP Child Health Plus/HARP/Select Plan |
$7.08
|
| Rate for Payer: CDPHP Commercial |
$11.27
|
| Rate for Payer: CDPHP Essential Plan |
$15.93
|
| Rate for Payer: CDPHP Medicare |
$5.18
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$11.20
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$8.50
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$7.08
|
| Rate for Payer: EmblemHealth Medicaid |
$7.08
|
| Rate for Payer: EmblemHealth Medicare |
$4.76
|
| Rate for Payer: EmblemHealth Select Care |
$10.08
|
| Rate for Payer: Fidelis Child Health Plus/Essential Plan/HARP/Medicaid |
$15.93
|
| Rate for Payer: Fidelis Medicare |
$5.34
|
| Rate for Payer: Galaxy Health Commercial |
$9.10
|
| Rate for Payer: Galaxy Health Workers Comp |
$10.41
|
| Rate for Payer: Hamaspik Choice Medicaid |
$708.00
|
| Rate for Payer: Hamaspik Choice Medicare |
$5.18
|
| Rate for Payer: Humana Medicare |
$5.18
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$7.70
|
| Rate for Payer: Local 1199SEIU Medicare |
$6.44
|
| Rate for Payer: MVP Health Care of NY Child Health Plus/Family Health Plus/HARP/Medicaid |
$708.00
|
| Rate for Payer: MVP Health Care of NY Commercial |
$10.50
|
| Rate for Payer: MVP Health Care of NY Essential Plan 1&2 |
$15.22
|
| Rate for Payer: MVP Health Care of NY Essential Plan 3&4 |
$15.22
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$7.88
|
| Rate for Payer: MVP Health Care of NY Medicare |
$5.44
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$19.32
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$7.08
|
| Rate for Payer: United Healthcare Commercial |
$19.32
|
| Rate for Payer: United Healthcare Medicare |
$5.18
|
| Rate for Payer: WellCare Child Health Plus/Family Health Plus/Medicaid |
$7.43
|
| Rate for Payer: WellCare Medicare |
$7.70
|
|
|
BUPRENORPHINE-NALOX 8-2MG FILM 8 ea, 30 eaches
|
Facility
|
IP
|
$14.00
|
|
|
Service Code
|
HCPCS J0574
|
| Hospital Charge Code |
4401490
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.30 |
| Max. Negotiated Rate |
$9.10 |
| Rate for Payer: Aetna of NY Commercial |
$7.70
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$6.30
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$6.30
|
| Rate for Payer: Cash Price |
$10.50
|
| Rate for Payer: Galaxy Health Commercial |
$9.10
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$7.70
|
| Rate for Payer: WellCare Medicare |
$7.70
|
|
|
BUPRENORPHINE ORAL 1MG
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
HCPCS J0571
|
| Hospital Charge Code |
4473006
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$24.00 |
| Rate for Payer: Aetna of NY Commercial |
$1.65
|
| Rate for Payer: Aetna of NY Medicare |
$1.38
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$1.35
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$1.35
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Essential Plan |
$0.54
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicaid |
$0.24
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$1.11
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$1.50
|
| Rate for Payer: Cash Price |
$2.25
|
| Rate for Payer: Cash Price |
$2.25
|
| Rate for Payer: CDPHP Child Health Plus/HARP/Select Plan |
$0.24
|
| Rate for Payer: CDPHP Commercial |
$2.42
|
| Rate for Payer: CDPHP Essential Plan |
$0.54
|
| Rate for Payer: CDPHP Medicare |
$1.11
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$2.40
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$0.29
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$0.24
|
| Rate for Payer: EmblemHealth Medicaid |
$0.24
|
| Rate for Payer: EmblemHealth Medicare |
$1.02
|
| Rate for Payer: EmblemHealth Select Care |
$2.16
|
| Rate for Payer: Fidelis Child Health Plus/Essential Plan/HARP/Medicaid |
$0.54
|
| Rate for Payer: Fidelis Medicare |
$1.14
|
| Rate for Payer: Galaxy Health Commercial |
$1.95
|
| Rate for Payer: Galaxy Health Workers Comp |
$0.35
|
| Rate for Payer: Hamaspik Choice Medicaid |
$24.00
|
| Rate for Payer: Hamaspik Choice Medicare |
$1.11
|
| Rate for Payer: Humana Medicare |
$1.11
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1.65
|
| Rate for Payer: Local 1199SEIU Medicare |
$1.38
|
| Rate for Payer: MVP Health Care of NY Child Health Plus/Family Health Plus/HARP/Medicaid |
$24.00
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2.25
|
| Rate for Payer: MVP Health Care of NY Essential Plan 1&2 |
$0.52
|
| Rate for Payer: MVP Health Care of NY Essential Plan 3&4 |
$0.52
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$1.69
|
| Rate for Payer: MVP Health Care of NY Medicare |
$1.17
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$2.31
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$0.24
|
| Rate for Payer: United Healthcare Commercial |
$2.31
|
| Rate for Payer: United Healthcare Medicare |
$1.11
|
| Rate for Payer: WellCare Child Health Plus/Family Health Plus/Medicaid |
$0.25
|
| Rate for Payer: WellCare Medicare |
$1.65
|
|
|
BUPRENORPHINE ORAL 1MG
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
HCPCS J0571
|
| Hospital Charge Code |
4473006
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.35 |
| Max. Negotiated Rate |
$1.95 |
| Rate for Payer: Aetna of NY Commercial |
$1.65
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$1.35
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$1.35
|
| Rate for Payer: Cash Price |
$2.25
|
| Rate for Payer: Galaxy Health Commercial |
$1.95
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1.65
|
| Rate for Payer: WellCare Medicare |
$1.65
|
|
|
BUPROPION HCL 150MG TABS 30 EA
|
Facility
|
IP
|
$14.42
|
|
|
Service Code
|
NDC 51079004720
|
| Hospital Charge Code |
4400118
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.93 |
| Max. Negotiated Rate |
$9.37 |
| Rate for Payer: Cash Price |
$10.82
|
| Rate for Payer: Galaxy Health Commercial |
$9.37
|
| Rate for Payer: WellCare Medicare |
$7.93
|
|
|
BUPROPION HCL 150MG TABS 30 EA
|
Facility
|
OP
|
$14.42
|
|
|
Service Code
|
NDC 51079004720
|
| Hospital Charge Code |
4400118
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.90 |
| Max. Negotiated Rate |
$11.61 |
| Rate for Payer: Aetna of NY Commercial |
$10.09
|
| Rate for Payer: Aetna of NY Medicare |
$6.63
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$10.82
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$10.82
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$5.34
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$7.21
|
| Rate for Payer: Cash Price |
$10.82
|
| Rate for Payer: CDPHP Commercial |
$11.61
|
| Rate for Payer: CDPHP Medicare |
$5.34
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$11.54
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$11.54
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$11.54
|
| Rate for Payer: EmblemHealth Medicaid |
$11.54
|
| Rate for Payer: EmblemHealth Medicare |
$4.90
|
| Rate for Payer: EmblemHealth Select Care |
$10.38
|
| Rate for Payer: Fidelis Medicare |
$5.50
|
| Rate for Payer: Galaxy Health Commercial |
$9.37
|
| Rate for Payer: Hamaspik Choice Medicare |
$5.34
|
| Rate for Payer: Humana Medicare |
$5.34
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$10.09
|
| Rate for Payer: Local 1199SEIU Medicare |
$6.63
|
| Rate for Payer: MVP Health Care of NY Commercial |
$10.82
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$8.12
|
| Rate for Payer: MVP Health Care of NY Medicare |
$5.60
|
| Rate for Payer: United Healthcare Medicare |
$5.34
|
| Rate for Payer: WellCare Medicare |
$7.93
|
|
|
BUPROPION HCL 75MG TABS 10X10EA
|
Facility
|
IP
|
$6.18
|
|
|
Service Code
|
NDC 51079094320
|
| Hospital Charge Code |
4400116
|
|
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
|
|
|
BUPROPION HCL 75MG TABS 10X10EA
|
Facility
|
OP
|
$6.18
|
|
|
Service Code
|
NDC 51079094320
|
| Hospital Charge Code |
4400116
|
|
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
|
|
|
BUPROPION SR 100 MG TAB
|
Facility
|
IP
|
$6.18
|
|
|
Service Code
|
NDC 68084069701
|
| Hospital Charge Code |
4409094
|
|
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
|
|
|
BUPROPION SR 100 MG TAB
|
Facility
|
OP
|
$6.18
|
|
|
Service Code
|
NDC 68084069701
|
| Hospital Charge Code |
4409094
|
|
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
|
|
|
BUPROPION SR 150MG
|
Facility
|
IP
|
$6.18
|
|
|
Service Code
|
NDC 51079039220
|
| Hospital Charge Code |
4409060
|
|
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
|
|
|
BUPROPION SR 150MG
|
Facility
|
OP
|
$6.18
|
|
|
Service Code
|
NDC 51079039220
|
| Hospital Charge Code |
4409060
|
|
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
|
|
|
BURN INITIAL TREAT FIRST DEGRE
|
Facility
|
IP
|
$573.00
|
|
|
Service Code
|
HCPCS 16000
|
| Hospital Charge Code |
4600045
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$372.45 |
| Max. Negotiated Rate |
$372.45 |
| Rate for Payer: Cash Price |
$429.75
|
| Rate for Payer: Galaxy Health Commercial |
$372.45
|
|
|
BURN INITIAL TREAT FIRST DEGRE
|
Facility
|
OP
|
$573.00
|
|
|
Service Code
|
HCPCS 16000
|
| Hospital Charge Code |
4600045
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$190.75 |
| Max. Negotiated Rate |
$1,189.18 |
| Rate for Payer: Aetna of NY Commercial |
$955.00
|
| Rate for Payer: Aetna of NY Medicare |
$263.58
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$950.93
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$1,189.18
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$212.01
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$286.50
|
| Rate for Payer: Cash Price |
$429.75
|
| Rate for Payer: Cash Price |
$429.75
|
| Rate for Payer: Cash Price |
$429.75
|
| Rate for Payer: Cash Price |
$429.75
|
| Rate for Payer: CDPHP Commercial |
$461.26
|
| Rate for Payer: CDPHP Medicare |
$212.01
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$1,182.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$458.40
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$458.40
|
| Rate for Payer: EmblemHealth Medicaid |
$458.40
|
| Rate for Payer: EmblemHealth Medicare |
$194.82
|
| Rate for Payer: EmblemHealth Select Care |
$1,064.00
|
| Rate for Payer: Fidelis Child Health Plus/Essential Plan/HARP/Medicaid |
$250.00
|
| Rate for Payer: Fidelis Medicare |
$218.37
|
| Rate for Payer: Galaxy Health Commercial |
$372.45
|
| Rate for Payer: Hamaspik Choice Medicare |
$212.01
|
| Rate for Payer: Humana Medicare |
$212.01
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$955.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$263.58
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,174.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$881.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$222.61
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$980.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$190.75
|
| Rate for Payer: United Healthcare Commercial |
$980.00
|
| Rate for Payer: United Healthcare Medicare |
$212.01
|
| Rate for Payer: WellCare Medicare |
$315.15
|
|
|
BURR OVAL 10 FLUTE 3.5MM (AR-9350OBT)
|
Facility
|
IP
|
$204.00
|
|
| Hospital Charge Code |
4473030
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$132.60 |
| Max. Negotiated Rate |
$132.60 |
| Rate for Payer: Cash Price |
$153.00
|
| Rate for Payer: Galaxy Health Commercial |
$132.60
|
|
|
BURR OVAL 10 FLUTE 3.5MM (AR-9350OBT)
|
Facility
|
OP
|
$204.00
|
|
| Hospital Charge Code |
4473030
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$69.36 |
| Max. Negotiated Rate |
$164.22 |
| Rate for Payer: Aetna of NY Commercial |
$142.80
|
| Rate for Payer: Aetna of NY Medicare |
$93.84
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$153.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$153.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$75.48
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$102.00
|
| Rate for Payer: Cash Price |
$153.00
|
| Rate for Payer: CDPHP Commercial |
$164.22
|
| Rate for Payer: CDPHP Medicare |
$75.48
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$163.20
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$163.20
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$163.20
|
| Rate for Payer: EmblemHealth Medicaid |
$163.20
|
| Rate for Payer: EmblemHealth Medicare |
$69.36
|
| Rate for Payer: EmblemHealth Select Care |
$146.88
|
| Rate for Payer: Fidelis Medicare |
$77.74
|
| Rate for Payer: Galaxy Health Commercial |
$132.60
|
| Rate for Payer: Hamaspik Choice Medicare |
$75.48
|
| Rate for Payer: Humana Medicare |
$75.48
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$142.80
|
| Rate for Payer: Local 1199SEIU Medicare |
$93.84
|
| Rate for Payer: MVP Health Care of NY Commercial |
$153.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$114.85
|
| Rate for Payer: MVP Health Care of NY Medicare |
$79.25
|
| Rate for Payer: United Healthcare Medicare |
$75.48
|
| Rate for Payer: WellCare Medicare |
$112.20
|
|
|
BURR ROUND 10 FLUTE 3.0MM (AR-9300RBT)
|
Facility
|
IP
|
$204.00
|
|
| Hospital Charge Code |
4473031
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$132.60 |
| Max. Negotiated Rate |
$132.60 |
| Rate for Payer: Cash Price |
$153.00
|
| Rate for Payer: Galaxy Health Commercial |
$132.60
|
|
|
BURR ROUND 10 FLUTE 3.0MM (AR-9300RBT)
|
Facility
|
OP
|
$204.00
|
|
| Hospital Charge Code |
4473031
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$69.36 |
| Max. Negotiated Rate |
$164.22 |
| Rate for Payer: Aetna of NY Commercial |
$142.80
|
| Rate for Payer: Aetna of NY Medicare |
$93.84
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$153.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$153.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$75.48
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$102.00
|
| Rate for Payer: Cash Price |
$153.00
|
| Rate for Payer: CDPHP Commercial |
$164.22
|
| Rate for Payer: CDPHP Medicare |
$75.48
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$163.20
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$163.20
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$163.20
|
| Rate for Payer: EmblemHealth Medicaid |
$163.20
|
| Rate for Payer: EmblemHealth Medicare |
$69.36
|
| Rate for Payer: EmblemHealth Select Care |
$146.88
|
| Rate for Payer: Fidelis Medicare |
$77.74
|
| Rate for Payer: Galaxy Health Commercial |
$132.60
|
| Rate for Payer: Hamaspik Choice Medicare |
$75.48
|
| Rate for Payer: Humana Medicare |
$75.48
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$142.80
|
| Rate for Payer: Local 1199SEIU Medicare |
$93.84
|
| Rate for Payer: MVP Health Care of NY Commercial |
$153.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$114.85
|
| Rate for Payer: MVP Health Care of NY Medicare |
$79.25
|
| Rate for Payer: United Healthcare Medicare |
$75.48
|
| Rate for Payer: WellCare Medicare |
$112.20
|
|
|
BUSPIRONE 15 MG
|
Facility
|
IP
|
$6.18
|
|
|
Service Code
|
NDC 51079096020
|
| Hospital Charge Code |
4409077
|
|
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
|
|
