|
DIALYVITE WITH ZINC TABLET 1 ea, 100 eaches
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
NDC 10542001210
|
| Hospital Charge Code |
4401362
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.30 |
| Max. Negotiated Rate |
$3.90 |
| Rate for Payer: Cash Price |
$4.50
|
| Rate for Payer: Galaxy Health Commercial |
$3.90
|
| Rate for Payer: WellCare Medicare |
$3.30
|
|
|
DIALYVITE WITH ZINC TABLET 1 ea, 100 eaches
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
NDC 10542001210
|
| Hospital Charge Code |
4401362
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.04 |
| Max. Negotiated Rate |
$4.83 |
| Rate for Payer: Aetna of NY Commercial |
$4.20
|
| Rate for Payer: Aetna of NY Medicare |
$2.76
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$4.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$4.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$2.22
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$3.00
|
| Rate for Payer: Cash Price |
$4.50
|
| Rate for Payer: CDPHP Commercial |
$4.83
|
| Rate for Payer: CDPHP Medicare |
$2.22
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$4.80
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$4.80
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$4.80
|
| Rate for Payer: EmblemHealth Medicaid |
$4.80
|
| Rate for Payer: EmblemHealth Medicare |
$2.04
|
| Rate for Payer: EmblemHealth Select Care |
$4.32
|
| Rate for Payer: Fidelis Medicare |
$2.29
|
| Rate for Payer: Galaxy Health Commercial |
$3.90
|
| Rate for Payer: Hamaspik Choice Medicare |
$2.22
|
| Rate for Payer: Humana Medicare |
$2.22
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$4.20
|
| Rate for Payer: Local 1199SEIU Medicare |
$2.76
|
| Rate for Payer: MVP Health Care of NY Commercial |
$4.50
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$3.38
|
| Rate for Payer: MVP Health Care of NY Medicare |
$2.33
|
| Rate for Payer: United Healthcare Medicare |
$2.22
|
| Rate for Payer: WellCare Medicare |
$3.30
|
|
|
DIAZEPAM 5MG/ML MDV 10X10ML
|
Facility
|
IP
|
$45.00
|
|
|
Service Code
|
HCPCS J3360
|
| Hospital Charge Code |
4400226
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.54 |
| Max. Negotiated Rate |
$29.25 |
| Rate for Payer: Aetna of NY Commercial |
$24.75
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$6.54
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$6.54
|
| Rate for Payer: Cash Price |
$33.75
|
| Rate for Payer: Cash Price |
$33.75
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$6.54
|
| Rate for Payer: EmblemHealth Select Care |
$6.54
|
| Rate for Payer: Galaxy Health Commercial |
$29.25
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$24.75
|
| Rate for Payer: WellCare Medicare |
$24.75
|
|
|
DIAZEPAM 5MG/ML MDV 10X10ML
|
Facility
|
OP
|
$45.00
|
|
|
Service Code
|
HCPCS J3360
|
| Hospital Charge Code |
4400226
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.54 |
| Max. Negotiated Rate |
$36.22 |
| Rate for Payer: Aetna of NY Commercial |
$24.75
|
| Rate for Payer: Aetna of NY Medicare |
$20.70
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$6.54
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$6.54
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$16.65
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$22.50
|
| Rate for Payer: Cash Price |
$33.75
|
| Rate for Payer: Cash Price |
$33.75
|
| Rate for Payer: CDPHP Commercial |
$36.22
|
| Rate for Payer: CDPHP Medicare |
$16.65
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$6.54
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$36.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$36.00
|
| Rate for Payer: EmblemHealth Medicaid |
$36.00
|
| Rate for Payer: EmblemHealth Medicare |
$15.30
|
| Rate for Payer: EmblemHealth Select Care |
$6.54
|
| Rate for Payer: Fidelis Medicare |
$17.15
|
| Rate for Payer: Galaxy Health Commercial |
$29.25
|
| Rate for Payer: Hamaspik Choice Medicare |
$16.65
|
| Rate for Payer: Humana Medicare |
$16.65
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$24.75
|
| Rate for Payer: Local 1199SEIU Medicare |
$20.70
|
| Rate for Payer: MVP Health Care of NY Commercial |
$33.75
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$25.34
|
| Rate for Payer: MVP Health Care of NY Medicare |
$17.48
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$8.66
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$6.54
|
| Rate for Payer: United Healthcare Commercial |
$8.66
|
| Rate for Payer: United Healthcare Medicare |
$16.65
|
| Rate for Payer: WellCare Medicare |
$24.75
|
|
|
DIAZEPAM 5MG/ML SYRN 10X2ML
|
Facility
|
IP
|
$9.00
|
|
| Hospital Charge Code |
4400224
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.95 |
| Max. Negotiated Rate |
$5.85 |
| Rate for Payer: Cash Price |
$6.75
|
| Rate for Payer: Galaxy Health Commercial |
$5.85
|
| Rate for Payer: WellCare Medicare |
$4.95
|
|
|
DIAZEPAM 5MG/ML SYRN 10X2ML
|
Facility
|
OP
|
$9.00
|
|
| Hospital Charge Code |
4400224
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.06 |
| Max. Negotiated Rate |
$7.24 |
| Rate for Payer: Aetna of NY Commercial |
$6.30
|
| Rate for Payer: Aetna of NY Medicare |
$4.14
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$6.75
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$6.75
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$3.33
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$4.50
|
| Rate for Payer: Cash Price |
$6.75
|
| Rate for Payer: CDPHP Commercial |
$7.24
|
| Rate for Payer: CDPHP Medicare |
$3.33
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$7.20
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$7.20
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$7.20
|
| Rate for Payer: EmblemHealth Medicaid |
$7.20
|
| Rate for Payer: EmblemHealth Medicare |
$3.06
|
| Rate for Payer: EmblemHealth Select Care |
$6.48
|
| Rate for Payer: Fidelis Medicare |
$3.43
|
| Rate for Payer: Galaxy Health Commercial |
$5.85
|
| Rate for Payer: Hamaspik Choice Medicare |
$3.33
|
| Rate for Payer: Humana Medicare |
$3.33
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$6.30
|
| Rate for Payer: Local 1199SEIU Medicare |
$4.14
|
| Rate for Payer: MVP Health Care of NY Commercial |
$6.75
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$5.07
|
| Rate for Payer: MVP Health Care of NY Medicare |
$3.50
|
| Rate for Payer: United Healthcare Medicare |
$3.33
|
| Rate for Payer: WellCare Medicare |
$4.95
|
|
|
DIAZEPAM 5 MG TAB
|
Facility
|
OP
|
$6.18
|
|
|
Service Code
|
NDC 51079028520
|
| Hospital Charge Code |
4408950
|
|
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
|
|
|
DIAZEPAM 5 MG TAB
|
Facility
|
IP
|
$6.18
|
|
|
Service Code
|
NDC 51079028520
|
| Hospital Charge Code |
4408950
|
|
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
|
|
|
DIAZEPAM INJ TO 5 MG
|
Facility
|
OP
|
$98.46
|
|
|
Service Code
|
HCPCS J3360
|
| Hospital Charge Code |
4400225
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.54 |
| Max. Negotiated Rate |
$79.26 |
| Rate for Payer: Aetna of NY Commercial |
$54.15
|
| Rate for Payer: Aetna of NY Medicare |
$45.29
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$6.54
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$6.54
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$36.43
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$49.23
|
| Rate for Payer: Cash Price |
$73.85
|
| Rate for Payer: Cash Price |
$73.85
|
| Rate for Payer: CDPHP Commercial |
$79.26
|
| Rate for Payer: CDPHP Medicare |
$36.43
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$6.54
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$78.77
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$78.77
|
| Rate for Payer: EmblemHealth Medicaid |
$78.77
|
| Rate for Payer: EmblemHealth Medicare |
$33.48
|
| Rate for Payer: EmblemHealth Select Care |
$6.54
|
| Rate for Payer: Fidelis Medicare |
$37.52
|
| Rate for Payer: Galaxy Health Commercial |
$64.00
|
| Rate for Payer: Hamaspik Choice Medicare |
$36.43
|
| Rate for Payer: Humana Medicare |
$36.43
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$54.15
|
| Rate for Payer: Local 1199SEIU Medicare |
$45.29
|
| Rate for Payer: MVP Health Care of NY Commercial |
$73.84
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$55.43
|
| Rate for Payer: MVP Health Care of NY Medicare |
$38.25
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$8.66
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$6.54
|
| Rate for Payer: United Healthcare Commercial |
$8.66
|
| Rate for Payer: United Healthcare Medicare |
$36.43
|
| Rate for Payer: WellCare Medicare |
$54.15
|
|
|
DIAZEPAM INJ TO 5 MG
|
Facility
|
IP
|
$98.46
|
|
|
Service Code
|
HCPCS J3360
|
| Hospital Charge Code |
4400225
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.54 |
| Max. Negotiated Rate |
$64.00 |
| Rate for Payer: Aetna of NY Commercial |
$54.15
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$6.54
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$6.54
|
| Rate for Payer: Cash Price |
$73.85
|
| Rate for Payer: Cash Price |
$73.85
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$6.54
|
| Rate for Payer: EmblemHealth Select Care |
$6.54
|
| Rate for Payer: Galaxy Health Commercial |
$64.00
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$54.15
|
| Rate for Payer: WellCare Medicare |
$54.15
|
|
|
DICLOFENAC EPOLAMINE 0.013 PTCH 6X5EA
|
Facility
|
IP
|
$38.37
|
|
|
Service Code
|
NDC 60793041105
|
| Hospital Charge Code |
4400297
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.10 |
| Max. Negotiated Rate |
$24.94 |
| Rate for Payer: Cash Price |
$28.78
|
| Rate for Payer: Galaxy Health Commercial |
$24.94
|
| Rate for Payer: WellCare Medicare |
$21.10
|
|
|
DICLOFENAC EPOLAMINE 0.013 PTCH 6X5EA
|
Facility
|
OP
|
$38.37
|
|
|
Service Code
|
NDC 60793041105
|
| Hospital Charge Code |
4400297
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.05 |
| Max. Negotiated Rate |
$30.89 |
| Rate for Payer: Aetna of NY Commercial |
$26.86
|
| Rate for Payer: Aetna of NY Medicare |
$17.65
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$28.78
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$28.78
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$14.20
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$19.18
|
| Rate for Payer: Cash Price |
$28.78
|
| Rate for Payer: CDPHP Commercial |
$30.89
|
| Rate for Payer: CDPHP Medicare |
$14.20
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$30.70
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$30.70
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$30.70
|
| Rate for Payer: EmblemHealth Medicaid |
$30.70
|
| Rate for Payer: EmblemHealth Medicare |
$13.05
|
| Rate for Payer: EmblemHealth Select Care |
$27.63
|
| Rate for Payer: Fidelis Medicare |
$14.62
|
| Rate for Payer: Galaxy Health Commercial |
$24.94
|
| Rate for Payer: Hamaspik Choice Medicare |
$14.20
|
| Rate for Payer: Humana Medicare |
$14.20
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$26.86
|
| Rate for Payer: Local 1199SEIU Medicare |
$17.65
|
| Rate for Payer: MVP Health Care of NY Commercial |
$28.78
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$21.60
|
| Rate for Payer: MVP Health Care of NY Medicare |
$14.91
|
| Rate for Payer: United Healthcare Medicare |
$14.20
|
| Rate for Payer: WellCare Medicare |
$21.10
|
|
|
DICLOFENAC OS 0.1%
|
Facility
|
OP
|
$138.28
|
|
|
Service Code
|
NDC 17478089225
|
| Hospital Charge Code |
4409007
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$47.02 |
| Max. Negotiated Rate |
$111.32 |
| Rate for Payer: Aetna of NY Commercial |
$96.80
|
| Rate for Payer: Aetna of NY Medicare |
$63.61
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$103.71
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$103.71
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$51.16
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$69.14
|
| Rate for Payer: Cash Price |
$103.71
|
| Rate for Payer: CDPHP Commercial |
$111.32
|
| Rate for Payer: CDPHP Medicare |
$51.16
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$110.62
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$110.62
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$110.62
|
| Rate for Payer: EmblemHealth Medicaid |
$110.62
|
| Rate for Payer: EmblemHealth Medicare |
$47.02
|
| Rate for Payer: EmblemHealth Select Care |
$99.56
|
| Rate for Payer: Fidelis Medicare |
$52.70
|
| Rate for Payer: Galaxy Health Commercial |
$89.88
|
| Rate for Payer: Hamaspik Choice Medicare |
$51.16
|
| Rate for Payer: Humana Medicare |
$51.16
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$96.80
|
| Rate for Payer: Local 1199SEIU Medicare |
$63.61
|
| Rate for Payer: MVP Health Care of NY Commercial |
$103.71
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$77.85
|
| Rate for Payer: MVP Health Care of NY Medicare |
$53.72
|
| Rate for Payer: United Healthcare Medicare |
$51.16
|
| Rate for Payer: WellCare Medicare |
$76.05
|
|
|
DICLOFENAC OS 0.1%
|
Facility
|
IP
|
$138.28
|
|
|
Service Code
|
NDC 17478089225
|
| Hospital Charge Code |
4409007
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$76.05 |
| Max. Negotiated Rate |
$89.88 |
| Rate for Payer: Cash Price |
$103.71
|
| Rate for Payer: Galaxy Health Commercial |
$89.88
|
| Rate for Payer: WellCare Medicare |
$76.05
|
|
|
DICLOXACILLIN SODIUM 500MG CAPS 100 EA
|
Facility
|
IP
|
$6.95
|
|
|
Service Code
|
NDC 00093312501
|
| Hospital Charge Code |
4400227
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.82 |
| Max. Negotiated Rate |
$4.52 |
| Rate for Payer: Cash Price |
$5.21
|
| Rate for Payer: Galaxy Health Commercial |
$4.52
|
| Rate for Payer: WellCare Medicare |
$3.82
|
|
|
DICLOXACILLIN SODIUM 500MG CAPS 100 EA
|
Facility
|
OP
|
$6.95
|
|
|
Service Code
|
NDC 00093312501
|
| Hospital Charge Code |
4400227
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.36 |
| Max. Negotiated Rate |
$5.59 |
| Rate for Payer: Aetna of NY Commercial |
$4.86
|
| Rate for Payer: Aetna of NY Medicare |
$3.20
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$5.21
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$5.21
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$2.57
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$3.48
|
| Rate for Payer: Cash Price |
$5.21
|
| Rate for Payer: CDPHP Commercial |
$5.59
|
| Rate for Payer: CDPHP Medicare |
$2.57
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$5.56
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$5.56
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$5.56
|
| Rate for Payer: EmblemHealth Medicaid |
$5.56
|
| Rate for Payer: EmblemHealth Medicare |
$2.36
|
| Rate for Payer: EmblemHealth Select Care |
$5.00
|
| Rate for Payer: Fidelis Medicare |
$2.65
|
| Rate for Payer: Galaxy Health Commercial |
$4.52
|
| Rate for Payer: Hamaspik Choice Medicare |
$2.57
|
| Rate for Payer: Humana Medicare |
$2.57
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$4.86
|
| Rate for Payer: Local 1199SEIU Medicare |
$3.20
|
| Rate for Payer: MVP Health Care of NY Commercial |
$5.21
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$3.91
|
| Rate for Payer: MVP Health Care of NY Medicare |
$2.70
|
| Rate for Payer: United Healthcare Medicare |
$2.57
|
| Rate for Payer: WellCare Medicare |
$3.82
|
|
|
DICYCLOMINE HCL 10MG CAPS 100 EA
|
Facility
|
OP
|
$6.18
|
|
|
Service Code
|
NDC 51079011820
|
| Hospital Charge Code |
4400228
|
|
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
|
|
|
DICYCLOMINE HCL 10MG CAPS 100 EA
|
Facility
|
IP
|
$6.18
|
|
|
Service Code
|
NDC 51079011820
|
| Hospital Charge Code |
4400228
|
|
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
|
|
|
DICYCLOMINE INJ TO 20 MG
|
Facility
|
OP
|
$124.37
|
|
|
Service Code
|
HCPCS J0500
|
| Hospital Charge Code |
4400098
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.98 |
| Max. Negotiated Rate |
$100.12 |
| Rate for Payer: Aetna of NY Commercial |
$68.40
|
| Rate for Payer: Aetna of NY Medicare |
$57.21
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$24.98
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$24.98
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$46.02
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$62.18
|
| Rate for Payer: Cash Price |
$93.28
|
| Rate for Payer: Cash Price |
$93.28
|
| Rate for Payer: CDPHP Commercial |
$100.12
|
| Rate for Payer: CDPHP Medicare |
$46.02
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$24.98
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$99.50
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$99.50
|
| Rate for Payer: EmblemHealth Medicaid |
$99.50
|
| Rate for Payer: EmblemHealth Medicare |
$42.29
|
| Rate for Payer: EmblemHealth Select Care |
$24.98
|
| Rate for Payer: Fidelis Medicare |
$47.40
|
| Rate for Payer: Galaxy Health Commercial |
$80.84
|
| Rate for Payer: Hamaspik Choice Medicare |
$46.02
|
| Rate for Payer: Humana Medicare |
$46.02
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$68.40
|
| Rate for Payer: Local 1199SEIU Medicare |
$57.21
|
| Rate for Payer: MVP Health Care of NY Commercial |
$93.28
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$70.02
|
| Rate for Payer: MVP Health Care of NY Medicare |
$48.32
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$41.98
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$24.99
|
| Rate for Payer: United Healthcare Commercial |
$41.98
|
| Rate for Payer: United Healthcare Medicare |
$46.02
|
| Rate for Payer: WellCare Medicare |
$68.40
|
|
|
DICYCLOMINE INJ TO 20 MG
|
Facility
|
IP
|
$124.37
|
|
|
Service Code
|
HCPCS J0500
|
| Hospital Charge Code |
4400098
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.98 |
| Max. Negotiated Rate |
$80.84 |
| Rate for Payer: Aetna of NY Commercial |
$68.40
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$24.98
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$24.98
|
| Rate for Payer: Cash Price |
$93.28
|
| Rate for Payer: Cash Price |
$93.28
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$24.98
|
| Rate for Payer: EmblemHealth Select Care |
$24.98
|
| Rate for Payer: Galaxy Health Commercial |
$80.84
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$68.40
|
| Rate for Payer: WellCare Medicare |
$68.40
|
|
|
DIGITAL BREAST TOMOSYNTHESIS BILATERAL (NON-MEDICARE)
|
Facility
|
OP
|
$284.00
|
|
|
Service Code
|
HCPCS 77062 TC
|
| Hospital Charge Code |
4150406
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$96.56 |
| Max. Negotiated Rate |
$475.00 |
| Rate for Payer: Aetna of NY Commercial |
$198.80
|
| Rate for Payer: Aetna of NY Medicare |
$130.64
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$213.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$213.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$105.08
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$142.00
|
| Rate for Payer: Cash Price |
$213.00
|
| Rate for Payer: Cash Price |
$213.00
|
| Rate for Payer: CDPHP Commercial |
$228.62
|
| Rate for Payer: CDPHP Medicare |
$105.08
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$198.80
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$227.20
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$227.20
|
| Rate for Payer: EmblemHealth Medicaid |
$227.20
|
| Rate for Payer: EmblemHealth Medicare |
$96.56
|
| Rate for Payer: EmblemHealth Select Care |
$184.60
|
| Rate for Payer: Fidelis Medicare |
$108.23
|
| Rate for Payer: Galaxy Health Commercial |
$184.60
|
| Rate for Payer: Hamaspik Choice Medicare |
$105.08
|
| Rate for Payer: Humana Medicare |
$105.08
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$198.80
|
| Rate for Payer: Local 1199SEIU Medicare |
$130.64
|
| Rate for Payer: MVP Health Care of NY Commercial |
$213.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$159.89
|
| Rate for Payer: MVP Health Care of NY Medicare |
$110.33
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$475.00
|
| Rate for Payer: United Healthcare Commercial |
$475.00
|
| Rate for Payer: United Healthcare Medicare |
$105.08
|
| Rate for Payer: WellCare Medicare |
$156.20
|
|
|
DIGITAL BREAST TOMOSYNTHESIS BILATERAL (NON-MEDICARE)
|
Facility
|
IP
|
$284.00
|
|
|
Service Code
|
HCPCS 77062 TC
|
| Hospital Charge Code |
4150406
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$184.60 |
| Max. Negotiated Rate |
$184.60 |
| Rate for Payer: Cash Price |
$213.00
|
| Rate for Payer: Galaxy Health Commercial |
$184.60
|
|
|
DIGITAL BREAST TOMOSYNTHESIS UNILATERAL, LEFT (NON-MEDICARE)
|
Facility
|
IP
|
$189.00
|
|
|
Service Code
|
HCPCS 77061 LT,TC
|
| Hospital Charge Code |
4150412
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$122.85 |
| Max. Negotiated Rate |
$122.85 |
| Rate for Payer: Cash Price |
$141.75
|
| Rate for Payer: Galaxy Health Commercial |
$122.85
|
|
|
DIGITAL BREAST TOMOSYNTHESIS UNILATERAL, LEFT (NON-MEDICARE)
|
Facility
|
OP
|
$189.00
|
|
|
Service Code
|
HCPCS 77061 LT,TC
|
| Hospital Charge Code |
4150412
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$64.26 |
| Max. Negotiated Rate |
$475.00 |
| Rate for Payer: Aetna of NY Commercial |
$132.30
|
| Rate for Payer: Aetna of NY Medicare |
$86.94
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$141.75
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$141.75
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$69.93
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$94.50
|
| Rate for Payer: Cash Price |
$141.75
|
| Rate for Payer: Cash Price |
$141.75
|
| Rate for Payer: CDPHP Commercial |
$152.14
|
| Rate for Payer: CDPHP Medicare |
$69.93
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$132.30
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$151.20
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$151.20
|
| Rate for Payer: EmblemHealth Medicaid |
$151.20
|
| Rate for Payer: EmblemHealth Medicare |
$64.26
|
| Rate for Payer: EmblemHealth Select Care |
$122.85
|
| Rate for Payer: Fidelis Medicare |
$72.03
|
| Rate for Payer: Galaxy Health Commercial |
$122.85
|
| Rate for Payer: Hamaspik Choice Medicare |
$69.93
|
| Rate for Payer: Humana Medicare |
$69.93
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$132.30
|
| Rate for Payer: Local 1199SEIU Medicare |
$86.94
|
| Rate for Payer: MVP Health Care of NY Commercial |
$141.75
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$106.41
|
| Rate for Payer: MVP Health Care of NY Medicare |
$73.43
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$475.00
|
| Rate for Payer: United Healthcare Commercial |
$475.00
|
| Rate for Payer: United Healthcare Medicare |
$69.93
|
| Rate for Payer: WellCare Medicare |
$103.95
|
|
|
DIGITAL BREAST TOMOSYNTHESIS UNILATERAL (NON-MEDICARE)
|
Facility
|
OP
|
$189.00
|
|
|
Service Code
|
HCPCS 77061 TC
|
| Hospital Charge Code |
4150405
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$64.26 |
| Max. Negotiated Rate |
$475.00 |
| Rate for Payer: Aetna of NY Commercial |
$132.30
|
| Rate for Payer: Aetna of NY Medicare |
$86.94
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$141.75
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$141.75
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$69.93
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$94.50
|
| Rate for Payer: Cash Price |
$141.75
|
| Rate for Payer: Cash Price |
$141.75
|
| Rate for Payer: CDPHP Commercial |
$152.14
|
| Rate for Payer: CDPHP Medicare |
$69.93
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$132.30
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$151.20
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$151.20
|
| Rate for Payer: EmblemHealth Medicaid |
$151.20
|
| Rate for Payer: EmblemHealth Medicare |
$64.26
|
| Rate for Payer: EmblemHealth Select Care |
$122.85
|
| Rate for Payer: Fidelis Medicare |
$72.03
|
| Rate for Payer: Galaxy Health Commercial |
$122.85
|
| Rate for Payer: Hamaspik Choice Medicare |
$69.93
|
| Rate for Payer: Humana Medicare |
$69.93
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$132.30
|
| Rate for Payer: Local 1199SEIU Medicare |
$86.94
|
| Rate for Payer: MVP Health Care of NY Commercial |
$141.75
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$106.41
|
| Rate for Payer: MVP Health Care of NY Medicare |
$73.43
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$475.00
|
| Rate for Payer: United Healthcare Commercial |
$475.00
|
| Rate for Payer: United Healthcare Medicare |
$69.93
|
| Rate for Payer: WellCare Medicare |
$103.95
|
|
