|
DOBUTAMINE HYDROCHLORIDE INJ, PER 250 MG
|
Facility
|
OP
|
$61.03
|
|
|
Service Code
|
HCPCS J1250
|
| Hospital Charge Code |
4450003
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.26 |
| Max. Negotiated Rate |
$49.13 |
| Rate for Payer: Aetna of NY Commercial |
$33.57
|
| Rate for Payer: Aetna of NY Medicare |
$28.07
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$9.26
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$9.26
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$22.58
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$30.52
|
| Rate for Payer: Cash Price |
$45.77
|
| Rate for Payer: Cash Price |
$45.77
|
| Rate for Payer: CDPHP Commercial |
$49.13
|
| Rate for Payer: CDPHP Medicare |
$22.58
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$9.26
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$48.82
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$48.82
|
| Rate for Payer: EmblemHealth Medicaid |
$48.82
|
| Rate for Payer: EmblemHealth Medicare |
$20.75
|
| Rate for Payer: EmblemHealth Select Care |
$9.26
|
| Rate for Payer: Fidelis Medicare |
$23.26
|
| Rate for Payer: Galaxy Health Commercial |
$39.67
|
| Rate for Payer: Hamaspik Choice Medicare |
$22.58
|
| Rate for Payer: Humana Medicare |
$22.58
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$33.57
|
| Rate for Payer: Local 1199SEIU Medicare |
$28.07
|
| Rate for Payer: MVP Health Care of NY Commercial |
$45.77
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$34.36
|
| Rate for Payer: MVP Health Care of NY Medicare |
$23.71
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$14.57
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$9.26
|
| Rate for Payer: United Healthcare Commercial |
$14.57
|
| Rate for Payer: United Healthcare Medicare |
$22.58
|
| Rate for Payer: WellCare Medicare |
$33.57
|
|
|
DOBUTAMINE HYDROCHLORIDE INJ, PER 250 MG
|
Facility
|
IP
|
$61.03
|
|
|
Service Code
|
HCPCS J1250
|
| Hospital Charge Code |
4450003
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.26 |
| Max. Negotiated Rate |
$39.67 |
| Rate for Payer: Aetna of NY Commercial |
$33.57
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$9.26
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$9.26
|
| Rate for Payer: Cash Price |
$45.77
|
| Rate for Payer: Cash Price |
$45.77
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$9.26
|
| Rate for Payer: EmblemHealth Select Care |
$9.26
|
| Rate for Payer: Galaxy Health Commercial |
$39.67
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$33.57
|
| Rate for Payer: WellCare Medicare |
$33.57
|
|
|
DOBUTAMINE HYDROCHLORIDE INJ, PER 250 MG
|
Facility
|
IP
|
$17.25
|
|
|
Service Code
|
HCPCS J1250
|
| Hospital Charge Code |
4400248
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.26 |
| Max. Negotiated Rate |
$11.21 |
| Rate for Payer: Aetna of NY Commercial |
$9.49
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$9.26
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$9.26
|
| Rate for Payer: Cash Price |
$12.94
|
| Rate for Payer: Cash Price |
$12.94
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$9.26
|
| Rate for Payer: EmblemHealth Select Care |
$9.26
|
| Rate for Payer: Galaxy Health Commercial |
$11.21
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$9.49
|
| Rate for Payer: WellCare Medicare |
$9.49
|
|
|
DOBUTAMINE HYDROCHLORIDE INJ, PER 250 MG
|
Facility
|
OP
|
$17.25
|
|
|
Service Code
|
HCPCS J1250
|
| Hospital Charge Code |
4400248
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.86 |
| Max. Negotiated Rate |
$14.57 |
| Rate for Payer: Aetna of NY Commercial |
$9.49
|
| Rate for Payer: Aetna of NY Medicare |
$7.94
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$9.26
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$9.26
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$6.38
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$8.62
|
| Rate for Payer: Cash Price |
$12.94
|
| Rate for Payer: Cash Price |
$12.94
|
| Rate for Payer: CDPHP Commercial |
$13.89
|
| Rate for Payer: CDPHP Medicare |
$6.38
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$9.26
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$13.80
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$13.80
|
| Rate for Payer: EmblemHealth Medicaid |
$13.80
|
| Rate for Payer: EmblemHealth Medicare |
$5.86
|
| Rate for Payer: EmblemHealth Select Care |
$9.26
|
| Rate for Payer: Fidelis Medicare |
$6.57
|
| Rate for Payer: Galaxy Health Commercial |
$11.21
|
| Rate for Payer: Hamaspik Choice Medicare |
$6.38
|
| Rate for Payer: Humana Medicare |
$6.38
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$9.49
|
| Rate for Payer: Local 1199SEIU Medicare |
$7.94
|
| Rate for Payer: MVP Health Care of NY Commercial |
$12.94
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$9.71
|
| Rate for Payer: MVP Health Care of NY Medicare |
$6.70
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$14.57
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$9.26
|
| Rate for Payer: United Healthcare Commercial |
$14.57
|
| Rate for Payer: United Healthcare Medicare |
$6.38
|
| Rate for Payer: WellCare Medicare |
$9.49
|
|
|
DOCU LIQUID 100 MG/10 ML 100 mg, 10 mL
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
NDC 50383077111
|
| Hospital Charge Code |
4401351
|
|
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
|
|
|
DOCU LIQUID 100 MG/10 ML 100 mg, 10 mL
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
NDC 50383077111
|
| Hospital Charge Code |
4401351
|
|
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
|
|
|
DOCUSATE 100 MG CAP
|
Facility
|
OP
|
$6.18
|
|
|
Service Code
|
NDC 00904645561
|
| Hospital Charge Code |
4401262
|
|
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
|
|
|
DOCUSATE 100 MG CAP
|
Facility
|
IP
|
$6.18
|
|
|
Service Code
|
NDC 00904645561
|
| Hospital Charge Code |
4401262
|
|
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
|
|
|
DONEPEZIL HCL 5 MG TABLET 5 mcg, 100 eaches
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
NDC 00904647761
|
| Hospital Charge Code |
4401518
|
|
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
|
|
|
DONEPEZIL HCL 5 MG TABLET 5 mcg, 100 eaches
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
NDC 00904647761
|
| Hospital Charge Code |
4401518
|
|
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
|
|
|
DONEPEZIL HCL 5MG TABS 10X10EA
|
Facility
|
IP
|
$6.18
|
|
|
Service Code
|
NDC 00904624261
|
| Hospital Charge Code |
4400068
|
|
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
|
|
|
DONEPEZIL HCL 5MG TABS 10X10EA
|
Facility
|
OP
|
$6.18
|
|
|
Service Code
|
NDC 00904624261
|
| Hospital Charge Code |
4400068
|
|
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
|
|
|
DONNATAL ELIXIR 5 mL, 5 mL
|
Facility
|
OP
|
$126.00
|
|
|
Service Code
|
NDC 66689006301
|
| Hospital Charge Code |
4401323
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$42.84 |
| Max. Negotiated Rate |
$101.43 |
| Rate for Payer: Aetna of NY Commercial |
$88.20
|
| Rate for Payer: Aetna of NY Medicare |
$57.96
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$94.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$94.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$46.62
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$63.00
|
| Rate for Payer: Cash Price |
$94.50
|
| Rate for Payer: CDPHP Commercial |
$101.43
|
| Rate for Payer: CDPHP Medicare |
$46.62
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$100.80
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$100.80
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$100.80
|
| Rate for Payer: EmblemHealth Medicaid |
$100.80
|
| Rate for Payer: EmblemHealth Medicare |
$42.84
|
| Rate for Payer: EmblemHealth Select Care |
$90.72
|
| Rate for Payer: Fidelis Medicare |
$48.02
|
| Rate for Payer: Galaxy Health Commercial |
$81.90
|
| Rate for Payer: Hamaspik Choice Medicare |
$46.62
|
| Rate for Payer: Humana Medicare |
$46.62
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$88.20
|
| Rate for Payer: Local 1199SEIU Medicare |
$57.96
|
| Rate for Payer: MVP Health Care of NY Commercial |
$94.50
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$70.94
|
| Rate for Payer: MVP Health Care of NY Medicare |
$48.95
|
| Rate for Payer: United Healthcare Medicare |
$46.62
|
| Rate for Payer: WellCare Medicare |
$69.30
|
|
|
DONNATAL ELIXIR 5 mL, 5 mL
|
Facility
|
IP
|
$126.00
|
|
|
Service Code
|
NDC 66689006301
|
| Hospital Charge Code |
4401323
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$69.30 |
| Max. Negotiated Rate |
$81.90 |
| Rate for Payer: Cash Price |
$94.50
|
| Rate for Payer: Galaxy Health Commercial |
$81.90
|
| Rate for Payer: WellCare Medicare |
$69.30
|
|
|
DOPAMINE INJECTION 40 MG
|
Facility
|
OP
|
$33.22
|
|
|
Service Code
|
HCPCS J1265
|
| Hospital Charge Code |
4450004
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.82 |
| Max. Negotiated Rate |
$26.74 |
| Rate for Payer: Aetna of NY Commercial |
$18.27
|
| Rate for Payer: Aetna of NY Medicare |
$15.28
|
| 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 |
$12.29
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$16.61
|
| Rate for Payer: Cash Price |
$24.92
|
| Rate for Payer: Cash Price |
$24.92
|
| Rate for Payer: CDPHP Commercial |
$26.74
|
| Rate for Payer: CDPHP Medicare |
$12.29
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$0.82
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$26.58
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$26.58
|
| Rate for Payer: EmblemHealth Medicaid |
$26.58
|
| Rate for Payer: EmblemHealth Medicare |
$11.29
|
| Rate for Payer: EmblemHealth Select Care |
$0.82
|
| Rate for Payer: Fidelis Medicare |
$12.66
|
| Rate for Payer: Galaxy Health Commercial |
$21.59
|
| Rate for Payer: Hamaspik Choice Medicare |
$12.29
|
| Rate for Payer: Humana Medicare |
$12.29
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$18.27
|
| Rate for Payer: Local 1199SEIU Medicare |
$15.28
|
| Rate for Payer: MVP Health Care of NY Commercial |
$24.92
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$18.70
|
| Rate for Payer: MVP Health Care of NY Medicare |
$12.91
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$1.16
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$0.82
|
| Rate for Payer: United Healthcare Commercial |
$1.16
|
| Rate for Payer: United Healthcare Medicare |
$12.29
|
| Rate for Payer: WellCare Medicare |
$18.27
|
|
|
DOPAMINE INJECTION 40 MG
|
Facility
|
IP
|
$33.22
|
|
|
Service Code
|
HCPCS J1265
|
| Hospital Charge Code |
4450004
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.82 |
| Max. Negotiated Rate |
$21.59 |
| Rate for Payer: Aetna of NY Commercial |
$18.27
|
| 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 |
$24.92
|
| Rate for Payer: Cash Price |
$24.92
|
| 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 |
$21.59
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$18.27
|
| Rate for Payer: WellCare Medicare |
$18.27
|
|
|
DOPPLER ECHO; COMPLETE
|
Facility
|
OP
|
$577.00
|
|
|
Service Code
|
HCPCS 93320
|
| Hospital Charge Code |
4480109
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$87.87 |
| Max. Negotiated Rate |
$464.48 |
| Rate for Payer: Aetna of NY Commercial |
$375.05
|
| Rate for Payer: Aetna of NY Medicare |
$265.42
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$432.75
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$432.75
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$213.49
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$288.50
|
| Rate for Payer: Cash Price |
$432.75
|
| Rate for Payer: Cash Price |
$432.75
|
| Rate for Payer: CDPHP Commercial |
$464.48
|
| Rate for Payer: CDPHP Medicare |
$213.49
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$403.90
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$461.60
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$461.60
|
| Rate for Payer: EmblemHealth Medicaid |
$461.60
|
| Rate for Payer: EmblemHealth Medicare |
$196.18
|
| Rate for Payer: EmblemHealth Select Care |
$375.05
|
| Rate for Payer: Fidelis Medicare |
$219.89
|
| Rate for Payer: Galaxy Health Commercial |
$375.05
|
| Rate for Payer: Hamaspik Choice Medicare |
$213.49
|
| Rate for Payer: Humana Medicare |
$213.49
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$375.05
|
| Rate for Payer: Local 1199SEIU Medicare |
$265.42
|
| Rate for Payer: MVP Health Care of NY Commercial |
$432.75
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$324.85
|
| Rate for Payer: MVP Health Care of NY Medicare |
$224.16
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$432.75
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$87.87
|
| Rate for Payer: United Healthcare Commercial |
$432.75
|
| Rate for Payer: United Healthcare Medicare |
$213.49
|
| Rate for Payer: WellCare Medicare |
$317.35
|
|
|
DOPPLER ECHO; COMPLETE
|
Facility
|
IP
|
$577.00
|
|
|
Service Code
|
HCPCS 93320
|
| Hospital Charge Code |
4480109
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$375.05 |
| Max. Negotiated Rate |
$375.05 |
| Rate for Payer: Cash Price |
$432.75
|
| Rate for Payer: Galaxy Health Commercial |
$375.05
|
|
|
DOPPLER ECHO; LIMITED/ F-UP
|
Facility
|
IP
|
$367.00
|
|
|
Service Code
|
HCPCS 93321
|
| Hospital Charge Code |
4480108
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$238.55 |
| Max. Negotiated Rate |
$238.55 |
| Rate for Payer: Cash Price |
$275.25
|
| Rate for Payer: Galaxy Health Commercial |
$238.55
|
|
|
DOPPLER ECHO; LIMITED/ F-UP
|
Facility
|
OP
|
$367.00
|
|
|
Service Code
|
HCPCS 93321
|
| Hospital Charge Code |
4480108
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$60.60 |
| Max. Negotiated Rate |
$295.44 |
| Rate for Payer: Aetna of NY Commercial |
$238.55
|
| Rate for Payer: Aetna of NY Medicare |
$168.82
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$275.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$275.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$135.79
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$183.50
|
| Rate for Payer: Cash Price |
$275.25
|
| Rate for Payer: Cash Price |
$275.25
|
| Rate for Payer: CDPHP Commercial |
$295.44
|
| Rate for Payer: CDPHP Medicare |
$135.79
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$256.90
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$293.60
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$293.60
|
| Rate for Payer: EmblemHealth Medicaid |
$293.60
|
| Rate for Payer: EmblemHealth Medicare |
$124.78
|
| Rate for Payer: EmblemHealth Select Care |
$238.55
|
| Rate for Payer: Fidelis Medicare |
$139.86
|
| Rate for Payer: Galaxy Health Commercial |
$238.55
|
| Rate for Payer: Hamaspik Choice Medicare |
$135.79
|
| Rate for Payer: Humana Medicare |
$135.79
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$238.55
|
| Rate for Payer: Local 1199SEIU Medicare |
$168.82
|
| Rate for Payer: MVP Health Care of NY Commercial |
$275.25
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$206.62
|
| Rate for Payer: MVP Health Care of NY Medicare |
$142.58
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$275.25
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$60.60
|
| Rate for Payer: United Healthcare Commercial |
$275.25
|
| Rate for Payer: United Healthcare Medicare |
$135.79
|
| Rate for Payer: WellCare Medicare |
$201.85
|
|
|
DORSAL PF NIGHT SPLINT LARGE
|
Facility
|
OP
|
$134.00
|
|
| Hospital Charge Code |
4471460
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$45.56 |
| Max. Negotiated Rate |
$107.87 |
| Rate for Payer: Aetna of NY Commercial |
$93.80
|
| Rate for Payer: Aetna of NY Medicare |
$61.64
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$100.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$100.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$49.58
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$67.00
|
| Rate for Payer: Cash Price |
$100.50
|
| Rate for Payer: CDPHP Commercial |
$107.87
|
| Rate for Payer: CDPHP Medicare |
$49.58
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$107.20
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$107.20
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$107.20
|
| Rate for Payer: EmblemHealth Medicaid |
$107.20
|
| Rate for Payer: EmblemHealth Medicare |
$45.56
|
| Rate for Payer: EmblemHealth Select Care |
$96.48
|
| Rate for Payer: Fidelis Medicare |
$51.07
|
| Rate for Payer: Galaxy Health Commercial |
$87.10
|
| Rate for Payer: Hamaspik Choice Medicare |
$49.58
|
| Rate for Payer: Humana Medicare |
$49.58
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$93.80
|
| Rate for Payer: Local 1199SEIU Medicare |
$61.64
|
| Rate for Payer: MVP Health Care of NY Commercial |
$100.50
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$75.44
|
| Rate for Payer: MVP Health Care of NY Medicare |
$52.06
|
| Rate for Payer: United Healthcare Medicare |
$49.58
|
| Rate for Payer: WellCare Medicare |
$73.70
|
|
|
DORSAL PF NIGHT SPLINT LARGE
|
Facility
|
IP
|
$134.00
|
|
| Hospital Charge Code |
4471460
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$87.10 |
| Max. Negotiated Rate |
$87.10 |
| Rate for Payer: Cash Price |
$100.50
|
| Rate for Payer: Galaxy Health Commercial |
$87.10
|
|
|
DORSAL PF NIGHT SPLINT MED
|
Facility
|
OP
|
$134.00
|
|
| Hospital Charge Code |
4471459
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$45.56 |
| Max. Negotiated Rate |
$107.87 |
| Rate for Payer: Aetna of NY Commercial |
$93.80
|
| Rate for Payer: Aetna of NY Medicare |
$61.64
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$100.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$100.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$49.58
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$67.00
|
| Rate for Payer: Cash Price |
$100.50
|
| Rate for Payer: CDPHP Commercial |
$107.87
|
| Rate for Payer: CDPHP Medicare |
$49.58
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$107.20
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$107.20
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$107.20
|
| Rate for Payer: EmblemHealth Medicaid |
$107.20
|
| Rate for Payer: EmblemHealth Medicare |
$45.56
|
| Rate for Payer: EmblemHealth Select Care |
$96.48
|
| Rate for Payer: Fidelis Medicare |
$51.07
|
| Rate for Payer: Galaxy Health Commercial |
$87.10
|
| Rate for Payer: Hamaspik Choice Medicare |
$49.58
|
| Rate for Payer: Humana Medicare |
$49.58
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$93.80
|
| Rate for Payer: Local 1199SEIU Medicare |
$61.64
|
| Rate for Payer: MVP Health Care of NY Commercial |
$100.50
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$75.44
|
| Rate for Payer: MVP Health Care of NY Medicare |
$52.06
|
| Rate for Payer: United Healthcare Medicare |
$49.58
|
| Rate for Payer: WellCare Medicare |
$73.70
|
|
|
DORSAL PF NIGHT SPLINT MED
|
Facility
|
IP
|
$134.00
|
|
| Hospital Charge Code |
4471459
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$87.10 |
| Max. Negotiated Rate |
$87.10 |
| Rate for Payer: Cash Price |
$100.50
|
| Rate for Payer: Galaxy Health Commercial |
$87.10
|
|
|
DORZOLAMIDE HCL 2% EYE DROPS 10 mL, 10 mL
|
Facility
|
IP
|
$200.00
|
|
|
Service Code
|
NDC 61314001910
|
| Hospital Charge Code |
4401334
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$110.00 |
| Max. Negotiated Rate |
$130.00 |
| Rate for Payer: Cash Price |
$150.00
|
| Rate for Payer: Galaxy Health Commercial |
$130.00
|
| Rate for Payer: WellCare Medicare |
$110.00
|
|
