|
CALDOLOR 800 MG/200 ML BAG 1 ea, 200 mL
|
Facility
|
IP
|
$74.00
|
|
|
Service Code
|
NDC 66220028411
|
| Hospital Charge Code |
4401437
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$40.70 |
| Max. Negotiated Rate |
$48.10 |
| Rate for Payer: Cash Price |
$55.50
|
| Rate for Payer: Galaxy Health Commercial |
$48.10
|
| Rate for Payer: WellCare Medicare |
$40.70
|
|
|
CANALITH REPOSITIONING PROC
|
Facility
|
IP
|
$131.00
|
|
|
Service Code
|
HCPCS 95992 GP
|
| Hospital Charge Code |
4650076
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$85.15 |
| Max. Negotiated Rate |
$85.15 |
| Rate for Payer: Cash Price |
$98.25
|
| Rate for Payer: Galaxy Health Commercial |
$85.15
|
|
|
CANALITH REPOSITIONING PROC
|
Facility
|
OP
|
$131.00
|
|
|
Service Code
|
HCPCS 95992 GP
|
| Hospital Charge Code |
4650076
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$19.65 |
| Max. Negotiated Rate |
$187.00 |
| Rate for Payer: Aetna of NY Commercial |
$115.00
|
| Rate for Payer: Aetna of NY Medicare |
$60.26
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$52.40
|
| Rate for Payer: Cash Price |
$98.25
|
| Rate for Payer: Cash Price |
$98.25
|
| Rate for Payer: Cash Price |
$98.25
|
| Rate for Payer: CDPHP Medicare |
$48.47
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$104.80
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$104.80
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$104.80
|
| Rate for Payer: EmblemHealth Medicaid |
$104.80
|
| Rate for Payer: EmblemHealth Medicare |
$44.54
|
| Rate for Payer: EmblemHealth Select Care |
$94.32
|
| Rate for Payer: Fidelis Medicare |
$52.40
|
| Rate for Payer: Galaxy Health Commercial |
$85.15
|
| Rate for Payer: Hamaspik Choice Medicare |
$52.40
|
| Rate for Payer: Humana Medicare |
$52.40
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$115.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$60.26
|
| Rate for Payer: MVP Health Care of NY Commercial |
$187.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$141.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$55.02
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$161.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$19.65
|
| Rate for Payer: United Healthcare Commercial |
$161.00
|
| Rate for Payer: United Healthcare Medicare |
$52.40
|
| Rate for Payer: WellCare Medicare |
$72.05
|
|
|
CANALITH REPOSITIONING PROC (MOD 59)
|
Facility
|
IP
|
$131.00
|
|
|
Service Code
|
HCPCS 95992 GP,59
|
| Hospital Charge Code |
4650391
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$85.15 |
| Max. Negotiated Rate |
$85.15 |
| Rate for Payer: Cash Price |
$98.25
|
| Rate for Payer: Galaxy Health Commercial |
$85.15
|
|
|
CANALITH REPOSITIONING PROC (MOD 59)
|
Facility
|
OP
|
$131.00
|
|
|
Service Code
|
HCPCS 95992 GP,59
|
| Hospital Charge Code |
4650391
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$19.65 |
| Max. Negotiated Rate |
$187.00 |
| Rate for Payer: Aetna of NY Commercial |
$115.00
|
| Rate for Payer: Aetna of NY Medicare |
$60.26
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$52.40
|
| Rate for Payer: Cash Price |
$98.25
|
| Rate for Payer: Cash Price |
$98.25
|
| Rate for Payer: Cash Price |
$98.25
|
| Rate for Payer: CDPHP Medicare |
$48.47
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$104.80
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$104.80
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$104.80
|
| Rate for Payer: EmblemHealth Medicaid |
$104.80
|
| Rate for Payer: EmblemHealth Medicare |
$44.54
|
| Rate for Payer: EmblemHealth Select Care |
$94.32
|
| Rate for Payer: Fidelis Medicare |
$52.40
|
| Rate for Payer: Galaxy Health Commercial |
$85.15
|
| Rate for Payer: Hamaspik Choice Medicare |
$52.40
|
| Rate for Payer: Humana Medicare |
$52.40
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$115.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$60.26
|
| Rate for Payer: MVP Health Care of NY Commercial |
$187.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$141.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$55.02
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$161.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$19.65
|
| Rate for Payer: United Healthcare Commercial |
$161.00
|
| Rate for Payer: United Healthcare Medicare |
$52.40
|
| Rate for Payer: WellCare Medicare |
$72.05
|
|
|
CANALITH REPOSITIONING PROC (MOD 59 W KX)
|
Facility
|
OP
|
$131.00
|
|
|
Service Code
|
HCPCS 95992 GP,59,KX
|
| Hospital Charge Code |
4650443
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$19.65 |
| Max. Negotiated Rate |
$187.00 |
| Rate for Payer: Aetna of NY Commercial |
$115.00
|
| Rate for Payer: Aetna of NY Medicare |
$60.26
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$52.40
|
| Rate for Payer: Cash Price |
$98.25
|
| Rate for Payer: Cash Price |
$98.25
|
| Rate for Payer: Cash Price |
$98.25
|
| Rate for Payer: CDPHP Medicare |
$48.47
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$104.80
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$104.80
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$104.80
|
| Rate for Payer: EmblemHealth Medicaid |
$104.80
|
| Rate for Payer: EmblemHealth Medicare |
$44.54
|
| Rate for Payer: EmblemHealth Select Care |
$94.32
|
| Rate for Payer: Fidelis Medicare |
$52.40
|
| Rate for Payer: Galaxy Health Commercial |
$85.15
|
| Rate for Payer: Hamaspik Choice Medicare |
$52.40
|
| Rate for Payer: Humana Medicare |
$52.40
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$115.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$60.26
|
| Rate for Payer: MVP Health Care of NY Commercial |
$187.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$141.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$55.02
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$161.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$19.65
|
| Rate for Payer: United Healthcare Commercial |
$161.00
|
| Rate for Payer: United Healthcare Medicare |
$52.40
|
| Rate for Payer: WellCare Medicare |
$72.05
|
|
|
CANALITH REPOSITIONING PROC (MOD 59 W KX)
|
Facility
|
IP
|
$131.00
|
|
|
Service Code
|
HCPCS 95992 GP,59,KX
|
| Hospital Charge Code |
4650443
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$85.15 |
| Max. Negotiated Rate |
$85.15 |
| Rate for Payer: Cash Price |
$98.25
|
| Rate for Payer: Galaxy Health Commercial |
$85.15
|
|
|
CANALITH REPOSITIONING PROC (W/ KX)
|
Facility
|
OP
|
$131.00
|
|
|
Service Code
|
HCPCS 95992 GP,KX
|
| Hospital Charge Code |
4650339
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$19.65 |
| Max. Negotiated Rate |
$187.00 |
| Rate for Payer: Aetna of NY Commercial |
$115.00
|
| Rate for Payer: Aetna of NY Medicare |
$60.26
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$52.40
|
| Rate for Payer: Cash Price |
$98.25
|
| Rate for Payer: Cash Price |
$98.25
|
| Rate for Payer: Cash Price |
$98.25
|
| Rate for Payer: CDPHP Medicare |
$48.47
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$104.80
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$104.80
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$104.80
|
| Rate for Payer: EmblemHealth Medicaid |
$104.80
|
| Rate for Payer: EmblemHealth Medicare |
$44.54
|
| Rate for Payer: EmblemHealth Select Care |
$94.32
|
| Rate for Payer: Fidelis Medicare |
$52.40
|
| Rate for Payer: Galaxy Health Commercial |
$85.15
|
| Rate for Payer: Hamaspik Choice Medicare |
$52.40
|
| Rate for Payer: Humana Medicare |
$52.40
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$115.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$60.26
|
| Rate for Payer: MVP Health Care of NY Commercial |
$187.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$141.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$55.02
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$161.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$19.65
|
| Rate for Payer: United Healthcare Commercial |
$161.00
|
| Rate for Payer: United Healthcare Medicare |
$52.40
|
| Rate for Payer: WellCare Medicare |
$72.05
|
|
|
CANALITH REPOSITIONING PROC (W/ KX)
|
Facility
|
IP
|
$131.00
|
|
|
Service Code
|
HCPCS 95992 GP,KX
|
| Hospital Charge Code |
4650339
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$85.15 |
| Max. Negotiated Rate |
$85.15 |
| Rate for Payer: Cash Price |
$98.25
|
| Rate for Payer: Galaxy Health Commercial |
$85.15
|
|
|
CANE
|
Facility
|
IP
|
$39.14
|
|
| Hospital Charge Code |
4479076
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$25.44 |
| Max. Negotiated Rate |
$25.44 |
| Rate for Payer: Cash Price |
$29.36
|
| Rate for Payer: Galaxy Health Commercial |
$25.44
|
|
|
CANE
|
Facility
|
OP
|
$39.14
|
|
| Hospital Charge Code |
4602606
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$5.87 |
| Max. Negotiated Rate |
$31.31 |
| Rate for Payer: Aetna of NY Commercial |
$27.40
|
| Rate for Payer: Aetna of NY Medicare |
$18.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$15.66
|
| Rate for Payer: Cash Price |
$29.36
|
| Rate for Payer: CDPHP Medicare |
$14.48
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$31.31
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$31.31
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$31.31
|
| Rate for Payer: EmblemHealth Medicaid |
$31.31
|
| Rate for Payer: EmblemHealth Medicare |
$13.31
|
| Rate for Payer: EmblemHealth Select Care |
$28.18
|
| Rate for Payer: Fidelis Medicare |
$15.66
|
| Rate for Payer: Galaxy Health Commercial |
$25.44
|
| Rate for Payer: Hamaspik Choice Medicare |
$15.66
|
| Rate for Payer: Humana Medicare |
$15.66
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$27.40
|
| Rate for Payer: Local 1199SEIU Medicare |
$18.00
|
| Rate for Payer: MVP Health Care of NY Commercial |
$29.36
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$22.04
|
| Rate for Payer: MVP Health Care of NY Medicare |
$16.44
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$5.87
|
| Rate for Payer: United Healthcare Medicare |
$15.66
|
| Rate for Payer: WellCare Medicare |
$21.53
|
|
|
CANE
|
Facility
|
OP
|
$39.14
|
|
| Hospital Charge Code |
4479076
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$5.87 |
| Max. Negotiated Rate |
$31.31 |
| Rate for Payer: Aetna of NY Commercial |
$27.40
|
| Rate for Payer: Aetna of NY Medicare |
$18.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$15.66
|
| Rate for Payer: Cash Price |
$29.36
|
| Rate for Payer: CDPHP Medicare |
$14.48
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$31.31
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$31.31
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$31.31
|
| Rate for Payer: EmblemHealth Medicaid |
$31.31
|
| Rate for Payer: EmblemHealth Medicare |
$13.31
|
| Rate for Payer: EmblemHealth Select Care |
$28.18
|
| Rate for Payer: Fidelis Medicare |
$15.66
|
| Rate for Payer: Galaxy Health Commercial |
$25.44
|
| Rate for Payer: Hamaspik Choice Medicare |
$15.66
|
| Rate for Payer: Humana Medicare |
$15.66
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$27.40
|
| Rate for Payer: Local 1199SEIU Medicare |
$18.00
|
| Rate for Payer: MVP Health Care of NY Commercial |
$29.36
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$22.04
|
| Rate for Payer: MVP Health Care of NY Medicare |
$16.44
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$5.87
|
| Rate for Payer: United Healthcare Medicare |
$15.66
|
| Rate for Payer: WellCare Medicare |
$21.53
|
|
|
CANE
|
Facility
|
IP
|
$39.14
|
|
| Hospital Charge Code |
4602606
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$25.44 |
| Max. Negotiated Rate |
$25.44 |
| Rate for Payer: Cash Price |
$29.36
|
| Rate for Payer: Galaxy Health Commercial |
$25.44
|
|
|
CANNULA 20GX100MMX10MM
|
Facility
|
OP
|
$818.85
|
|
| Hospital Charge Code |
4479216
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$122.83 |
| Max. Negotiated Rate |
$655.08 |
| Rate for Payer: Aetna of NY Commercial |
$573.20
|
| Rate for Payer: Aetna of NY Medicare |
$376.67
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$327.54
|
| Rate for Payer: Cash Price |
$614.14
|
| Rate for Payer: CDPHP Medicare |
$302.97
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$655.08
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$655.08
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$655.08
|
| Rate for Payer: EmblemHealth Medicaid |
$655.08
|
| Rate for Payer: EmblemHealth Medicare |
$278.41
|
| Rate for Payer: EmblemHealth Select Care |
$589.57
|
| Rate for Payer: Fidelis Medicare |
$327.54
|
| Rate for Payer: Galaxy Health Commercial |
$532.25
|
| Rate for Payer: Hamaspik Choice Medicare |
$327.54
|
| Rate for Payer: Humana Medicare |
$327.54
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$573.20
|
| Rate for Payer: Local 1199SEIU Medicare |
$376.67
|
| Rate for Payer: MVP Health Care of NY Commercial |
$614.14
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$461.01
|
| Rate for Payer: MVP Health Care of NY Medicare |
$343.92
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$122.83
|
| Rate for Payer: United Healthcare Medicare |
$327.54
|
| Rate for Payer: WellCare Medicare |
$450.37
|
|
|
CANNULA 20GX100MMX10MM
|
Facility
|
IP
|
$818.85
|
|
| Hospital Charge Code |
4479216
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$532.25 |
| Max. Negotiated Rate |
$532.25 |
| Rate for Payer: Cash Price |
$614.14
|
| Rate for Payer: Galaxy Health Commercial |
$532.25
|
|
|
CANNULA CURVED SHARP 10MMX100MM 20GA
|
Facility
|
OP
|
$81.37
|
|
| Hospital Charge Code |
4479273
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$12.21 |
| Max. Negotiated Rate |
$65.10 |
| Rate for Payer: Aetna of NY Commercial |
$56.96
|
| Rate for Payer: Aetna of NY Medicare |
$37.43
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$32.55
|
| Rate for Payer: Cash Price |
$61.03
|
| Rate for Payer: CDPHP Medicare |
$30.11
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$65.10
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$65.10
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$65.10
|
| Rate for Payer: EmblemHealth Medicaid |
$65.10
|
| Rate for Payer: EmblemHealth Medicare |
$27.67
|
| Rate for Payer: EmblemHealth Select Care |
$58.59
|
| Rate for Payer: Fidelis Medicare |
$32.55
|
| Rate for Payer: Galaxy Health Commercial |
$52.89
|
| Rate for Payer: Hamaspik Choice Medicare |
$32.55
|
| Rate for Payer: Humana Medicare |
$32.55
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$56.96
|
| Rate for Payer: Local 1199SEIU Medicare |
$37.43
|
| Rate for Payer: MVP Health Care of NY Commercial |
$61.03
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$45.81
|
| Rate for Payer: MVP Health Care of NY Medicare |
$34.18
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$12.21
|
| Rate for Payer: United Healthcare Medicare |
$32.55
|
| Rate for Payer: WellCare Medicare |
$44.75
|
|
|
CANNULA CURVED SHARP 10MMX100MM 20GA
|
Facility
|
IP
|
$81.37
|
|
| Hospital Charge Code |
4479273
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$52.89 |
| Max. Negotiated Rate |
$52.89 |
| Rate for Payer: Cash Price |
$61.03
|
| Rate for Payer: Galaxy Health Commercial |
$52.89
|
|
|
CAPSUREFIX NOVUS
|
Facility
|
IP
|
$2,479.21
|
|
| Hospital Charge Code |
4471352
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$1,611.49 |
| Max. Negotiated Rate |
$1,611.49 |
| Rate for Payer: Cash Price |
$1,859.41
|
| Rate for Payer: Galaxy Health Commercial |
$1,611.49
|
|
|
CAPSUREFIX NOVUS
|
Facility
|
OP
|
$2,479.21
|
|
| Hospital Charge Code |
4471352
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$371.88 |
| Max. Negotiated Rate |
$1,983.37 |
| Rate for Payer: Aetna of NY Commercial |
$1,735.45
|
| Rate for Payer: Aetna of NY Medicare |
$1,140.44
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$991.68
|
| Rate for Payer: Cash Price |
$1,859.41
|
| Rate for Payer: CDPHP Medicare |
$917.31
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$1,983.37
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$1,983.37
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$1,983.37
|
| Rate for Payer: EmblemHealth Medicaid |
$1,983.37
|
| Rate for Payer: EmblemHealth Medicare |
$842.93
|
| Rate for Payer: EmblemHealth Select Care |
$1,785.03
|
| Rate for Payer: Fidelis Medicare |
$991.68
|
| Rate for Payer: Galaxy Health Commercial |
$1,611.49
|
| Rate for Payer: Hamaspik Choice Medicare |
$991.68
|
| Rate for Payer: Humana Medicare |
$991.68
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,735.45
|
| Rate for Payer: Local 1199SEIU Medicare |
$1,140.44
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,859.41
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$1,395.80
|
| Rate for Payer: MVP Health Care of NY Medicare |
$1,041.27
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$371.88
|
| Rate for Payer: United Healthcare Medicare |
$991.68
|
| Rate for Payer: WellCare Medicare |
$1,363.57
|
|
|
CAPSUREFIX NOVUS II
|
Facility
|
IP
|
$2,479.21
|
|
| Hospital Charge Code |
4471351
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$1,611.49 |
| Max. Negotiated Rate |
$1,611.49 |
| Rate for Payer: Cash Price |
$1,859.41
|
| Rate for Payer: Galaxy Health Commercial |
$1,611.49
|
|
|
CAPSUREFIX NOVUS II
|
Facility
|
OP
|
$2,479.21
|
|
| Hospital Charge Code |
4471351
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$371.88 |
| Max. Negotiated Rate |
$1,983.37 |
| Rate for Payer: Aetna of NY Commercial |
$1,735.45
|
| Rate for Payer: Aetna of NY Medicare |
$1,140.44
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$991.68
|
| Rate for Payer: Cash Price |
$1,859.41
|
| Rate for Payer: CDPHP Medicare |
$917.31
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$1,983.37
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$1,983.37
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$1,983.37
|
| Rate for Payer: EmblemHealth Medicaid |
$1,983.37
|
| Rate for Payer: EmblemHealth Medicare |
$842.93
|
| Rate for Payer: EmblemHealth Select Care |
$1,785.03
|
| Rate for Payer: Fidelis Medicare |
$991.68
|
| Rate for Payer: Galaxy Health Commercial |
$1,611.49
|
| Rate for Payer: Hamaspik Choice Medicare |
$991.68
|
| Rate for Payer: Humana Medicare |
$991.68
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,735.45
|
| Rate for Payer: Local 1199SEIU Medicare |
$1,140.44
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,859.41
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$1,395.80
|
| Rate for Payer: MVP Health Care of NY Medicare |
$1,041.27
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$371.88
|
| Rate for Payer: United Healthcare Medicare |
$991.68
|
| Rate for Payer: WellCare Medicare |
$1,363.57
|
|
|
CAPSUREFIX NOVUS III
|
Facility
|
OP
|
$2,479.21
|
|
| Hospital Charge Code |
4471350
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$371.88 |
| Max. Negotiated Rate |
$1,983.37 |
| Rate for Payer: Aetna of NY Commercial |
$1,735.45
|
| Rate for Payer: Aetna of NY Medicare |
$1,140.44
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$991.68
|
| Rate for Payer: Cash Price |
$1,859.41
|
| Rate for Payer: CDPHP Medicare |
$917.31
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$1,983.37
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$1,983.37
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$1,983.37
|
| Rate for Payer: EmblemHealth Medicaid |
$1,983.37
|
| Rate for Payer: EmblemHealth Medicare |
$842.93
|
| Rate for Payer: EmblemHealth Select Care |
$1,785.03
|
| Rate for Payer: Fidelis Medicare |
$991.68
|
| Rate for Payer: Galaxy Health Commercial |
$1,611.49
|
| Rate for Payer: Hamaspik Choice Medicare |
$991.68
|
| Rate for Payer: Humana Medicare |
$991.68
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,735.45
|
| Rate for Payer: Local 1199SEIU Medicare |
$1,140.44
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,859.41
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$1,395.80
|
| Rate for Payer: MVP Health Care of NY Medicare |
$1,041.27
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$371.88
|
| Rate for Payer: United Healthcare Medicare |
$991.68
|
| Rate for Payer: WellCare Medicare |
$1,363.57
|
|
|
CAPSUREFIX NOVUS III
|
Facility
|
IP
|
$2,479.21
|
|
| Hospital Charge Code |
4471350
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$1,611.49 |
| Max. Negotiated Rate |
$1,611.49 |
| Rate for Payer: Cash Price |
$1,859.41
|
| Rate for Payer: Galaxy Health Commercial |
$1,611.49
|
|
|
CAPTOPRIL 12.5MG TABS 10X10EA
|
Facility
|
OP
|
$6.18
|
|
|
Service Code
|
NDC 51079086301
|
| Hospital Charge Code |
4400128
|
|
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
|
|
|
CAPTOPRIL 12.5MG TABS 10X10EA
|
Facility
|
IP
|
$6.18
|
|
|
Service Code
|
NDC 51079086301
|
| Hospital Charge Code |
4400128
|
|
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
|
|
