|
BUPIVACAINE-DEXTR 0.75% AMP 1 ea, 2 mL
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
NDC 409361301
|
| Hospital Charge Code |
4401309
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.90 |
| Max. Negotiated Rate |
$4.80 |
| Rate for Payer: Aetna of NY Commercial |
$4.20
|
| Rate for Payer: Aetna of NY Medicare |
$2.76
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$2.40
|
| Rate for Payer: Cash Price |
$4.50
|
| Rate for Payer: CDPHP Medicare |
$2.22
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$4.80
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$4.80
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$4.80
|
| Rate for Payer: EmblemHealth Medicaid |
$4.80
|
| Rate for Payer: EmblemHealth Medicare |
$2.04
|
| Rate for Payer: EmblemHealth Select Care |
$4.32
|
| Rate for Payer: Fidelis Medicare |
$2.40
|
| Rate for Payer: Galaxy Health Commercial |
$3.90
|
| Rate for Payer: Hamaspik Choice Medicare |
$2.40
|
| Rate for Payer: Humana Medicare |
$2.40
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$4.20
|
| Rate for Payer: Local 1199SEIU Medicare |
$2.76
|
| Rate for Payer: MVP Health Care of NY Commercial |
$4.50
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$3.38
|
| Rate for Payer: MVP Health Care of NY Medicare |
$2.52
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$0.90
|
| Rate for Payer: United Healthcare Medicare |
$2.40
|
| Rate for Payer: WellCare Medicare |
$3.30
|
|
|
BUPIVACAINE/DEXTROSE 7.5MG/ML AMPS 10X2M
|
Facility
|
OP
|
$14.68
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
4400485
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.20 |
| Max. Negotiated Rate |
$11.74 |
| Rate for Payer: Aetna of NY Medicare |
$6.75
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$5.87
|
| Rate for Payer: Cash Price |
$11.01
|
| Rate for Payer: CDPHP Medicare |
$5.43
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$11.74
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$11.74
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$11.74
|
| Rate for Payer: EmblemHealth Medicaid |
$11.74
|
| Rate for Payer: EmblemHealth Medicare |
$4.99
|
| Rate for Payer: EmblemHealth Select Care |
$10.57
|
| Rate for Payer: Fidelis Medicare |
$5.87
|
| Rate for Payer: Galaxy Health Commercial |
$9.54
|
| Rate for Payer: Hamaspik Choice Medicare |
$5.87
|
| Rate for Payer: Humana Medicare |
$5.87
|
| Rate for Payer: Local 1199SEIU Medicare |
$6.75
|
| Rate for Payer: MVP Health Care of NY Commercial |
$11.01
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$8.26
|
| Rate for Payer: MVP Health Care of NY Medicare |
$6.17
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$2.20
|
| Rate for Payer: United Healthcare Medicare |
$5.87
|
| Rate for Payer: WellCare Medicare |
$8.07
|
|
|
BUPIVACAINE/DEXTROSE 7.5MG/ML AMPS 10X2M
|
Facility
|
IP
|
$14.68
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
4400485
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.07 |
| Max. Negotiated Rate |
$9.54 |
| Rate for Payer: Aetna of NY Commercial |
$8.07
|
| Rate for Payer: Cash Price |
$11.01
|
| Rate for Payer: Galaxy Health Commercial |
$9.54
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$8.07
|
| Rate for Payer: WellCare Medicare |
$8.07
|
|
|
BUPIVACAINE HCL 2.5MG/ML MDV 50 ML
|
Facility
|
IP
|
$6.18
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
4400483
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.40 |
| Max. Negotiated Rate |
$4.02 |
| Rate for Payer: Aetna of NY Commercial |
$3.40
|
| 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 2.5MG/ML MDV 50 ML
|
Facility
|
OP
|
$6.18
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
4400483
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.93 |
| Max. Negotiated Rate |
$4.94 |
| Rate for Payer: Aetna of NY Medicare |
$2.84
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$2.47
|
| Rate for Payer: Cash Price |
$4.64
|
| Rate for Payer: CDPHP Medicare |
$2.29
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$4.94
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$4.94
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$4.94
|
| Rate for Payer: EmblemHealth Medicaid |
$4.94
|
| Rate for Payer: EmblemHealth Medicare |
$2.10
|
| Rate for Payer: EmblemHealth Select Care |
$4.45
|
| Rate for Payer: Fidelis Medicare |
$2.47
|
| Rate for Payer: Galaxy Health Commercial |
$4.02
|
| Rate for Payer: Hamaspik Choice Medicare |
$2.47
|
| Rate for Payer: Humana Medicare |
$2.47
|
| Rate for Payer: Local 1199SEIU Medicare |
$2.84
|
| Rate for Payer: MVP Health Care of NY Commercial |
$4.63
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$3.48
|
| Rate for Payer: MVP Health Care of NY Medicare |
$2.60
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$0.93
|
| Rate for Payer: United Healthcare Medicare |
$2.47
|
| Rate for Payer: WellCare Medicare |
$3.40
|
|
|
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 |
$3.40 |
| Max. Negotiated Rate |
$4.02 |
| Rate for Payer: Aetna of NY Commercial |
$3.40
|
| 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 |
$0.93 |
| Max. Negotiated Rate |
$4.94 |
| Rate for Payer: Aetna of NY Medicare |
$2.84
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$2.47
|
| Rate for Payer: Cash Price |
$4.64
|
| Rate for Payer: CDPHP Medicare |
$2.29
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$4.94
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$4.94
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$4.94
|
| Rate for Payer: EmblemHealth Medicaid |
$4.94
|
| Rate for Payer: EmblemHealth Medicare |
$2.10
|
| Rate for Payer: EmblemHealth Select Care |
$4.45
|
| Rate for Payer: Fidelis Medicare |
$2.47
|
| Rate for Payer: Galaxy Health Commercial |
$4.02
|
| Rate for Payer: Hamaspik Choice Medicare |
$2.47
|
| Rate for Payer: Humana Medicare |
$2.47
|
| Rate for Payer: Local 1199SEIU Medicare |
$2.84
|
| Rate for Payer: MVP Health Care of NY Commercial |
$4.63
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$3.48
|
| Rate for Payer: MVP Health Care of NY Medicare |
$2.60
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$0.93
|
| Rate for Payer: United Healthcare Medicare |
$2.47
|
| Rate for Payer: WellCare Medicare |
$3.40
|
|
|
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 |
$29.15 |
| Max. Negotiated Rate |
$34.45 |
| Rate for Payer: Aetna of NY Commercial |
$29.15
|
| 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 |
$7.95 |
| Max. Negotiated Rate |
$42.40 |
| Rate for Payer: Aetna of NY Medicare |
$24.38
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$21.20
|
| Rate for Payer: Cash Price |
$39.75
|
| Rate for Payer: Cash Price |
$39.75
|
| 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 |
$21.20
|
| Rate for Payer: Galaxy Health Commercial |
$34.45
|
| Rate for Payer: Hamaspik Choice Medicare |
$21.20
|
| Rate for Payer: Humana Medicare |
$21.20
|
| 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 |
$22.26
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$30.18
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$7.95
|
| Rate for Payer: United Healthcare Commercial |
$30.18
|
| Rate for Payer: United Healthcare Medicare |
$21.20
|
| 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 |
$2.40 |
| Max. Negotiated Rate |
$12.80 |
| 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) Medicare |
$6.40
|
| Rate for Payer: Cash Price |
$12.00
|
| 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 |
$6.40
|
| Rate for Payer: Galaxy Health Commercial |
$10.40
|
| Rate for Payer: Hamaspik Choice Medicare |
$6.40
|
| Rate for Payer: Humana Medicare |
$6.40
|
| 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 |
$6.72
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$2.40
|
| Rate for Payer: United Healthcare Medicare |
$6.40
|
| Rate for Payer: WellCare Medicare |
$8.80
|
|
|
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 |
$7.70 |
| Max. Negotiated Rate |
$9.10 |
| Rate for Payer: Aetna of NY Commercial |
$7.70
|
| 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-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 |
$2.10 |
| Max. Negotiated Rate |
$19.32 |
| Rate for Payer: Aetna of NY Medicare |
$6.44
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$5.60
|
| Rate for Payer: Cash Price |
$10.50
|
| Rate for Payer: Cash Price |
$10.50
|
| 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 |
$10.31
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$8.59
|
| Rate for Payer: EmblemHealth Medicaid |
$8.59
|
| Rate for Payer: EmblemHealth Medicare |
$4.76
|
| Rate for Payer: EmblemHealth Select Care |
$10.08
|
| Rate for Payer: Fidelis Medicare |
$5.60
|
| Rate for Payer: Galaxy Health Commercial |
$9.10
|
| Rate for Payer: Galaxy Health Workers Comp |
$8.42
|
| Rate for Payer: Hamaspik Choice Medicaid |
$8.59
|
| Rate for Payer: Hamaspik Choice Medicare |
$5.60
|
| Rate for Payer: Humana Medicare |
$5.60
|
| Rate for Payer: Local 1199SEIU Medicare |
$6.44
|
| Rate for Payer: MVP Health Care of NY Child Health Plus/Family Health Plus/HARP/Medicaid |
$9.02
|
| Rate for Payer: MVP Health Care of NY Commercial |
$10.50
|
| Rate for Payer: MVP Health Care of NY Essential Plan 1&2 |
$18.47
|
| Rate for Payer: MVP Health Care of NY Essential Plan 3&4 |
$18.47
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$7.88
|
| Rate for Payer: MVP Health Care of NY Medicare |
$5.88
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$19.32
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$2.10
|
| Rate for Payer: United Healthcare Commercial |
$19.32
|
| Rate for Payer: United Healthcare Medicare |
$5.60
|
| Rate for Payer: WellCare Child Health Plus/Family Health Plus/Medicaid |
$9.02
|
| Rate for Payer: WellCare Medicare |
$7.70
|
|
|
BUPRENORPHINE ORAL 1MG
|
Facility
|
OP
|
$3.09
|
|
|
Service Code
|
HCPCS J0571
|
| Hospital Charge Code |
4473006
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$2.47 |
| Rate for Payer: Aetna of NY Medicare |
$1.42
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$1.24
|
| Rate for Payer: Cash Price |
$2.32
|
| Rate for Payer: Cash Price |
$2.32
|
| Rate for Payer: CDPHP Medicare |
$1.14
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$2.47
|
| 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 |
$1.05
|
| Rate for Payer: EmblemHealth Select Care |
$2.22
|
| Rate for Payer: Fidelis Medicare |
$1.24
|
| Rate for Payer: Galaxy Health Commercial |
$2.01
|
| Rate for Payer: Galaxy Health Workers Comp |
$0.24
|
| Rate for Payer: Hamaspik Choice Medicaid |
$0.24
|
| Rate for Payer: Hamaspik Choice Medicare |
$1.24
|
| Rate for Payer: Humana Medicare |
$1.24
|
| Rate for Payer: Local 1199SEIU Medicare |
$1.42
|
| Rate for Payer: MVP Health Care of NY Child Health Plus/Family Health Plus/HARP/Medicaid |
$0.25
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2.32
|
| 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 |
$1.74
|
| Rate for Payer: MVP Health Care of NY Medicare |
$1.30
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$2.31
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$0.46
|
| Rate for Payer: United Healthcare Commercial |
$2.31
|
| Rate for Payer: United Healthcare Medicare |
$1.24
|
| Rate for Payer: WellCare Child Health Plus/Family Health Plus/Medicaid |
$0.25
|
| Rate for Payer: WellCare Medicare |
$1.70
|
|
|
BUPRENORPHINE ORAL 1MG
|
Facility
|
IP
|
$3.09
|
|
|
Service Code
|
HCPCS J0571
|
| Hospital Charge Code |
4473006
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.70 |
| Max. Negotiated Rate |
$2.01 |
| Rate for Payer: Aetna of NY Commercial |
$1.70
|
| Rate for Payer: Cash Price |
$2.32
|
| Rate for Payer: Galaxy Health Commercial |
$2.01
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1.70
|
| Rate for Payer: WellCare Medicare |
$1.70
|
|
|
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 |
$2.16 |
| Max. Negotiated Rate |
$11.54 |
| 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) Medicare |
$5.77
|
| Rate for Payer: Cash Price |
$10.82
|
| 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 |
$5.77
|
| Rate for Payer: Galaxy Health Commercial |
$9.37
|
| Rate for Payer: Hamaspik Choice Medicare |
$5.77
|
| Rate for Payer: Humana Medicare |
$5.77
|
| 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 |
$10.81
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$8.12
|
| Rate for Payer: MVP Health Care of NY Medicare |
$6.06
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$2.16
|
| Rate for Payer: United Healthcare Medicare |
$5.77
|
| Rate for Payer: WellCare Medicare |
$7.93
|
|
|
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 75MG TABS 10X10EA
|
Facility
|
OP
|
$6.18
|
|
|
Service Code
|
NDC 51079094320
|
| Hospital Charge Code |
4400116
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.93 |
| Max. Negotiated Rate |
$4.94 |
| Rate for Payer: Aetna of NY Commercial |
$4.33
|
| Rate for Payer: Aetna of NY Medicare |
$2.84
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$2.47
|
| Rate for Payer: Cash Price |
$4.64
|
| Rate for Payer: CDPHP Medicare |
$2.29
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$4.94
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$4.94
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$4.94
|
| Rate for Payer: EmblemHealth Medicaid |
$4.94
|
| Rate for Payer: EmblemHealth Medicare |
$2.10
|
| Rate for Payer: EmblemHealth Select Care |
$4.45
|
| Rate for Payer: Fidelis Medicare |
$2.47
|
| Rate for Payer: Galaxy Health Commercial |
$4.02
|
| Rate for Payer: Hamaspik Choice Medicare |
$2.47
|
| Rate for Payer: Humana Medicare |
$2.47
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$4.33
|
| Rate for Payer: Local 1199SEIU Medicare |
$2.84
|
| Rate for Payer: MVP Health Care of NY Commercial |
$4.63
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$3.48
|
| Rate for Payer: MVP Health Care of NY Medicare |
$2.60
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$0.93
|
| Rate for Payer: United Healthcare Medicare |
$2.47
|
| Rate for Payer: WellCare Medicare |
$3.40
|
|
|
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 SR 100 MG TAB
|
Facility
|
OP
|
$6.18
|
|
|
Service Code
|
NDC 68084069701
|
| Hospital Charge Code |
4409094
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.93 |
| Max. Negotiated Rate |
$4.94 |
| Rate for Payer: Aetna of NY Commercial |
$4.33
|
| Rate for Payer: Aetna of NY Medicare |
$2.84
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$2.47
|
| Rate for Payer: Cash Price |
$4.64
|
| Rate for Payer: CDPHP Medicare |
$2.29
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$4.94
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$4.94
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$4.94
|
| Rate for Payer: EmblemHealth Medicaid |
$4.94
|
| Rate for Payer: EmblemHealth Medicare |
$2.10
|
| Rate for Payer: EmblemHealth Select Care |
$4.45
|
| Rate for Payer: Fidelis Medicare |
$2.47
|
| Rate for Payer: Galaxy Health Commercial |
$4.02
|
| Rate for Payer: Hamaspik Choice Medicare |
$2.47
|
| Rate for Payer: Humana Medicare |
$2.47
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$4.33
|
| Rate for Payer: Local 1199SEIU Medicare |
$2.84
|
| Rate for Payer: MVP Health Care of NY Commercial |
$4.63
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$3.48
|
| Rate for Payer: MVP Health Care of NY Medicare |
$2.60
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$0.93
|
| Rate for Payer: United Healthcare Medicare |
$2.47
|
| Rate for Payer: WellCare Medicare |
$3.40
|
|
|
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 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 |
$0.93 |
| Max. Negotiated Rate |
$4.94 |
| Rate for Payer: Aetna of NY Commercial |
$4.33
|
| Rate for Payer: Aetna of NY Medicare |
$2.84
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$2.47
|
| Rate for Payer: Cash Price |
$4.64
|
| Rate for Payer: CDPHP Medicare |
$2.29
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$4.94
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$4.94
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$4.94
|
| Rate for Payer: EmblemHealth Medicaid |
$4.94
|
| Rate for Payer: EmblemHealth Medicare |
$2.10
|
| Rate for Payer: EmblemHealth Select Care |
$4.45
|
| Rate for Payer: Fidelis Medicare |
$2.47
|
| Rate for Payer: Galaxy Health Commercial |
$4.02
|
| Rate for Payer: Hamaspik Choice Medicare |
$2.47
|
| Rate for Payer: Humana Medicare |
$2.47
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$4.33
|
| Rate for Payer: Local 1199SEIU Medicare |
$2.84
|
| Rate for Payer: MVP Health Care of NY Commercial |
$4.63
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$3.48
|
| Rate for Payer: MVP Health Care of NY Medicare |
$2.60
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$0.93
|
| Rate for Payer: United Healthcare Medicare |
$2.47
|
| Rate for Payer: WellCare Medicare |
$3.40
|
|
|
BURN INITIAL TREAT FIRST DEGRE
|
Facility
|
IP
|
$615.00
|
|
|
Service Code
|
HCPCS 16000
|
| Hospital Charge Code |
4600045
|
|
Hospital Revenue Code
|
450
|
| 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
|
|
|
BURN INITIAL TREAT FIRST DEGRE
|
Facility
|
OP
|
$615.00
|
|
|
Service Code
|
HCPCS 16000
|
| Hospital Charge Code |
4600045
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$92.25 |
| Max. Negotiated Rate |
$1,234.00 |
| Rate for Payer: Aetna of NY Commercial |
$1,000.00
|
| 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: Cash Price |
$461.25
|
| Rate for Payer: Cash Price |
$461.25
|
| Rate for Payer: CDPHP Medicare |
$227.55
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$1,206.00
|
| 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 |
$1,085.00
|
| 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 |
$1,000.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$282.90
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,234.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$925.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$258.30
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$1,009.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$92.25
|
| Rate for Payer: United Healthcare Commercial |
$1,009.00
|
| Rate for Payer: United Healthcare Medicare |
$246.00
|
| Rate for Payer: WellCare Medicare |
$338.25
|
|
