|
DILAT XST TRC NEW ACCESS RCS
|
Facility
|
OP
|
$9,975.00
|
|
|
Service Code
|
HCPCS 50437
|
| Hospital Charge Code |
4853034
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$2,017.33 |
| Max. Negotiated Rate |
$8,029.88 |
| Rate for Payer: Aetna of NY Commercial |
$6,982.50
|
| Rate for Payer: Aetna of NY Medicare |
$4,588.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$2,017.33
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$2,521.93
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$3,690.75
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$4,987.50
|
| Rate for Payer: Cash Price |
$7,481.25
|
| Rate for Payer: Cash Price |
$7,481.25
|
| Rate for Payer: Cash Price |
$7,481.25
|
| Rate for Payer: CDPHP Commercial |
$8,029.88
|
| Rate for Payer: CDPHP Medicare |
$3,690.75
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$7,980.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$7,980.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$7,980.00
|
| Rate for Payer: EmblemHealth Medicaid |
$7,980.00
|
| Rate for Payer: EmblemHealth Medicare |
$3,391.50
|
| Rate for Payer: EmblemHealth Select Care |
$7,182.00
|
| Rate for Payer: Fidelis Medicare |
$3,801.47
|
| Rate for Payer: Galaxy Health Commercial |
$6,483.75
|
| Rate for Payer: Hamaspik Choice Medicare |
$3,690.75
|
| Rate for Payer: Humana Medicare |
$3,690.75
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$6,982.50
|
| Rate for Payer: Local 1199SEIU Medicare |
$4,588.50
|
| Rate for Payer: MVP Health Care of NY Commercial |
$7,481.25
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$5,615.92
|
| Rate for Payer: MVP Health Care of NY Medicare |
$3,875.29
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$3,321.58
|
| Rate for Payer: United Healthcare Medicare |
$3,690.75
|
| Rate for Payer: WellCare Medicare |
$5,486.25
|
|
|
DILAT XST TRC NEW ACCESS RCS
|
Facility
|
IP
|
$9,975.00
|
|
|
Service Code
|
HCPCS 50437
|
| Hospital Charge Code |
4853034
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$6,483.75 |
| Max. Negotiated Rate |
$6,483.75 |
| Rate for Payer: Cash Price |
$7,481.25
|
| Rate for Payer: Galaxy Health Commercial |
$6,483.75
|
|
|
DILTIAZEM HCL 120MG CAPS 100 EA
|
Facility
|
OP
|
$6.18
|
|
|
Service Code
|
NDC 63739001410
|
| Hospital Charge Code |
4400237
|
|
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
|
|
|
DILTIAZEM HCL 120MG CAPS 100 EA
|
Facility
|
IP
|
$6.18
|
|
|
Service Code
|
NDC 63739001410
|
| Hospital Charge Code |
4400237
|
|
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
|
|
|
DILTIAZEM HCL 180MG CAPS 100 EA
|
Facility
|
IP
|
$6.18
|
|
|
Service Code
|
NDC 60687020611
|
| Hospital Charge Code |
4400238
|
|
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
|
|
|
DILTIAZEM HCL 180MG CAPS 100 EA
|
Facility
|
OP
|
$6.18
|
|
|
Service Code
|
NDC 60687020611
|
| Hospital Charge Code |
4400238
|
|
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
|
|
|
DILTIAZEM HCL 30MG TABS 100 EA
|
Facility
|
OP
|
$6.18
|
|
|
Service Code
|
NDC 63739007910
|
| Hospital Charge Code |
4400231
|
|
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
|
|
|
DILTIAZEM HCL 30MG TABS 100 EA
|
Facility
|
IP
|
$6.18
|
|
|
Service Code
|
NDC 63739007910
|
| Hospital Charge Code |
4400231
|
|
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
|
|
|
DILTIAZEM HCL 5MG/ML SDV 10X10ML
|
Facility
|
OP
|
$6.00
|
|
| Hospital Charge Code |
4400235
|
|
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
|
|
|
DILTIAZEM HCL 5MG/ML SDV 10X10ML
|
Facility
|
IP
|
$6.00
|
|
| Hospital Charge Code |
4400235
|
|
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
|
|
|
DILTIAZEM HCL 5MG/ML SDV 10X25ML
|
Facility
|
IP
|
$23.35
|
|
|
Service Code
|
NDC 00641601501
|
| Hospital Charge Code |
4400233
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.84 |
| Max. Negotiated Rate |
$15.18 |
| Rate for Payer: Cash Price |
$17.51
|
| Rate for Payer: Galaxy Health Commercial |
$15.18
|
| Rate for Payer: WellCare Medicare |
$12.84
|
|
|
DILTIAZEM HCL 5MG/ML SDV 10X25ML
|
Facility
|
OP
|
$23.35
|
|
|
Service Code
|
NDC 00641601501
|
| Hospital Charge Code |
4400233
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.94 |
| Max. Negotiated Rate |
$18.80 |
| Rate for Payer: Aetna of NY Commercial |
$16.34
|
| Rate for Payer: Aetna of NY Medicare |
$10.74
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$17.51
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$17.51
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$8.64
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$11.68
|
| Rate for Payer: Cash Price |
$17.51
|
| Rate for Payer: CDPHP Commercial |
$18.80
|
| Rate for Payer: CDPHP Medicare |
$8.64
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$18.68
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$18.68
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$18.68
|
| Rate for Payer: EmblemHealth Medicaid |
$18.68
|
| Rate for Payer: EmblemHealth Medicare |
$7.94
|
| Rate for Payer: EmblemHealth Select Care |
$16.81
|
| Rate for Payer: Fidelis Medicare |
$8.90
|
| Rate for Payer: Galaxy Health Commercial |
$15.18
|
| Rate for Payer: Hamaspik Choice Medicare |
$8.64
|
| Rate for Payer: Humana Medicare |
$8.64
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$16.34
|
| Rate for Payer: Local 1199SEIU Medicare |
$10.74
|
| Rate for Payer: MVP Health Care of NY Commercial |
$17.51
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$13.15
|
| Rate for Payer: MVP Health Care of NY Medicare |
$9.07
|
| Rate for Payer: United Healthcare Medicare |
$8.64
|
| Rate for Payer: WellCare Medicare |
$12.84
|
|
|
DILTIAZEM HCL 5MG/ML SDV 10X5ML
|
Facility
|
OP
|
$9.00
|
|
|
Service Code
|
NDC 00641601310
|
| Hospital Charge Code |
4400232
|
|
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
|
|
|
DILTIAZEM HCL 5MG/ML SDV 10X5ML
|
Facility
|
IP
|
$9.00
|
|
|
Service Code
|
NDC 00641601310
|
| Hospital Charge Code |
4400232
|
|
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
|
|
|
DIPHENHYDRAMINE HCL 12.5MG/5ML LIQD 4 OZ
|
Facility
|
IP
|
$6.18
|
|
|
Service Code
|
NDC 68094002262
|
| Hospital Charge Code |
4400240
|
|
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
|
|
|
DIPHENHYDRAMINE HCL 12.5MG/5ML LIQD 4 OZ
|
Facility
|
OP
|
$6.18
|
|
|
Service Code
|
NDC 68094002262
|
| Hospital Charge Code |
4400240
|
|
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
|
|
|
DIPHENHYDRAMINE HCL 25MG CAPS 10X10EA
|
Facility
|
IP
|
$6.18
|
|
|
Service Code
|
NDC 00904530661
|
| Hospital Charge Code |
4400241
|
|
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
|
|
|
DIPHENHYDRAMINE HCL 25MG CAPS 10X10EA
|
Facility
|
OP
|
$6.18
|
|
|
Service Code
|
NDC 00904530661
|
| Hospital Charge Code |
4400241
|
|
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
|
|
|
DIPHENHYDRAMINE HCL, UP TO 50 MG
|
Facility
|
IP
|
$6.18
|
|
|
Service Code
|
HCPCS J1200
|
| Hospital Charge Code |
4400242
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.82 |
| 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 |
$0.82
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$0.82
|
| Rate for Payer: Cash Price |
$4.64
|
| Rate for Payer: Cash Price |
$4.64
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$0.82
|
| Rate for Payer: EmblemHealth Select Care |
$0.82
|
| 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
|
|
|
DIPHENHYDRAMINE HCL, UP TO 50 MG
|
Facility
|
OP
|
$6.18
|
|
|
Service Code
|
HCPCS J1200
|
| Hospital Charge Code |
4400242
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.82 |
| 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 |
$0.82
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$0.82
|
| 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: 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 |
$0.82
|
| 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 |
$0.82
|
| 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: Oxford Health Plans Freedom/Liberty/Metro |
$1.75
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$0.82
|
| Rate for Payer: United Healthcare Commercial |
$1.75
|
| Rate for Payer: United Healthcare Medicare |
$2.29
|
| Rate for Payer: WellCare Medicare |
$3.40
|
|
|
DIPHENOXYLATE/ATROPINE 2.5-0.025MG TABS
|
Facility
|
IP
|
$6.18
|
|
|
Service Code
|
NDC 00378041501
|
| Hospital Charge Code |
4400243
|
|
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
|
|
|
DIPHENOXYLATE/ATROPINE 2.5-0.025MG TABS
|
Facility
|
OP
|
$6.18
|
|
|
Service Code
|
NDC 00378041501
|
| Hospital Charge Code |
4400243
|
|
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
|
|
|
DIPHTH PERTUSSIS(ADACEL)TET VAC SYRN 10X
|
Facility
|
IP
|
$141.88
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
4400110
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$39.09 |
| Max. Negotiated Rate |
$92.22 |
| Rate for Payer: Aetna of NY Commercial |
$78.03
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$39.09
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$39.09
|
| Rate for Payer: Cash Price |
$106.41
|
| Rate for Payer: Cash Price |
$106.41
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$39.09
|
| Rate for Payer: EmblemHealth Select Care |
$39.09
|
| Rate for Payer: Galaxy Health Commercial |
$92.22
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$78.03
|
| Rate for Payer: WellCare Medicare |
$78.03
|
|
|
DIPHTH PERTUSSIS(ADACEL)TET VAC SYRN 10X
|
Facility
|
OP
|
$141.88
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
4400110
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$39.09 |
| Max. Negotiated Rate |
$114.21 |
| Rate for Payer: Aetna of NY Commercial |
$78.03
|
| Rate for Payer: Aetna of NY Medicare |
$65.26
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$39.09
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$39.09
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$52.50
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$70.94
|
| Rate for Payer: Cash Price |
$106.41
|
| Rate for Payer: Cash Price |
$106.41
|
| Rate for Payer: CDPHP Commercial |
$114.21
|
| Rate for Payer: CDPHP Medicare |
$52.50
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$39.09
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$113.50
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$113.50
|
| Rate for Payer: EmblemHealth Medicaid |
$113.50
|
| Rate for Payer: EmblemHealth Medicare |
$48.24
|
| Rate for Payer: EmblemHealth Select Care |
$39.09
|
| Rate for Payer: Fidelis Medicare |
$54.07
|
| Rate for Payer: Galaxy Health Commercial |
$92.22
|
| Rate for Payer: Hamaspik Choice Medicare |
$52.50
|
| Rate for Payer: Humana Medicare |
$52.50
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$78.03
|
| Rate for Payer: Local 1199SEIU Medicare |
$65.26
|
| Rate for Payer: MVP Health Care of NY Commercial |
$106.41
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$79.88
|
| Rate for Payer: MVP Health Care of NY Medicare |
$55.12
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$63.94
|
| Rate for Payer: United Healthcare Commercial |
$63.94
|
| Rate for Payer: United Healthcare Medicare |
$52.50
|
| Rate for Payer: WellCare Medicare |
$78.03
|
|
|
DIPYRIDAMOLE 25 MG TAB
|
Facility
|
OP
|
$6.18
|
|
|
Service Code
|
NDC 64980013301
|
| Hospital Charge Code |
4409110
|
|
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
|
|
