|
DORZOLAMIDE HCL 2% EYE DROPS 10 mL, 10 mL
|
Facility
|
OP
|
$200.00
|
|
|
Service Code
|
NDC 61314001910
|
| Hospital Charge Code |
4401334
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$68.00 |
| Max. Negotiated Rate |
$161.00 |
| Rate for Payer: Aetna of NY Commercial |
$140.00
|
| Rate for Payer: Aetna of NY Medicare |
$92.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$150.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$150.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$74.00
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$100.00
|
| Rate for Payer: Cash Price |
$150.00
|
| Rate for Payer: CDPHP Commercial |
$161.00
|
| Rate for Payer: CDPHP Medicare |
$74.00
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$160.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$160.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$160.00
|
| Rate for Payer: EmblemHealth Medicaid |
$160.00
|
| Rate for Payer: EmblemHealth Medicare |
$68.00
|
| Rate for Payer: EmblemHealth Select Care |
$144.00
|
| Rate for Payer: Fidelis Medicare |
$76.22
|
| Rate for Payer: Galaxy Health Commercial |
$130.00
|
| Rate for Payer: Hamaspik Choice Medicare |
$74.00
|
| Rate for Payer: Humana Medicare |
$74.00
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$140.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$92.00
|
| Rate for Payer: MVP Health Care of NY Commercial |
$150.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$112.60
|
| Rate for Payer: MVP Health Care of NY Medicare |
$77.70
|
| Rate for Payer: United Healthcare Medicare |
$74.00
|
| Rate for Payer: WellCare Medicare |
$110.00
|
|
|
DORZOLAMIDE/TIMOLOL 2-0.5% DROP 10 ML
|
Facility
|
OP
|
$208.58
|
|
|
Service Code
|
NDC 24208048610
|
| Hospital Charge Code |
4400255
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$70.92 |
| Max. Negotiated Rate |
$167.91 |
| Rate for Payer: Aetna of NY Commercial |
$146.01
|
| Rate for Payer: Aetna of NY Medicare |
$95.95
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$156.44
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$156.44
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$77.17
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$104.29
|
| Rate for Payer: Cash Price |
$156.44
|
| Rate for Payer: CDPHP Commercial |
$167.91
|
| Rate for Payer: CDPHP Medicare |
$77.17
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$166.86
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$166.86
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$166.86
|
| Rate for Payer: EmblemHealth Medicaid |
$166.86
|
| Rate for Payer: EmblemHealth Medicare |
$70.92
|
| Rate for Payer: EmblemHealth Select Care |
$150.18
|
| Rate for Payer: Fidelis Medicare |
$79.49
|
| Rate for Payer: Galaxy Health Commercial |
$135.58
|
| Rate for Payer: Hamaspik Choice Medicare |
$77.17
|
| Rate for Payer: Humana Medicare |
$77.17
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$146.01
|
| Rate for Payer: Local 1199SEIU Medicare |
$95.95
|
| Rate for Payer: MVP Health Care of NY Commercial |
$156.44
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$117.43
|
| Rate for Payer: MVP Health Care of NY Medicare |
$81.03
|
| Rate for Payer: United Healthcare Medicare |
$77.17
|
| Rate for Payer: WellCare Medicare |
$114.72
|
|
|
DORZOLAMIDE/TIMOLOL 2-0.5% DROP 10 ML
|
Facility
|
IP
|
$208.58
|
|
|
Service Code
|
NDC 24208048610
|
| Hospital Charge Code |
4400255
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$114.72 |
| Max. Negotiated Rate |
$135.58 |
| Rate for Payer: Cash Price |
$156.44
|
| Rate for Payer: Galaxy Health Commercial |
$135.58
|
| Rate for Payer: WellCare Medicare |
$114.72
|
|
|
DOXAPRAM HCL 20MG/ML MDV 6X20ML
|
Facility
|
OP
|
$7.73
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
4400254
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.63 |
| Max. Negotiated Rate |
$6.22 |
| Rate for Payer: Aetna of NY Commercial |
$4.25
|
| Rate for Payer: Aetna of NY Medicare |
$3.56
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$3.48
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$3.48
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$2.86
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$3.86
|
| Rate for Payer: Cash Price |
$5.80
|
| Rate for Payer: CDPHP Commercial |
$6.22
|
| Rate for Payer: CDPHP Medicare |
$2.86
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$6.18
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$6.18
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$6.18
|
| Rate for Payer: EmblemHealth Medicaid |
$6.18
|
| Rate for Payer: EmblemHealth Medicare |
$2.63
|
| Rate for Payer: EmblemHealth Select Care |
$5.57
|
| Rate for Payer: Fidelis Medicare |
$2.95
|
| Rate for Payer: Galaxy Health Commercial |
$5.02
|
| Rate for Payer: Hamaspik Choice Medicare |
$2.86
|
| Rate for Payer: Humana Medicare |
$2.86
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$4.25
|
| Rate for Payer: Local 1199SEIU Medicare |
$3.56
|
| Rate for Payer: MVP Health Care of NY Commercial |
$5.80
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$4.35
|
| Rate for Payer: MVP Health Care of NY Medicare |
$3.00
|
| Rate for Payer: United Healthcare Medicare |
$2.86
|
| Rate for Payer: WellCare Medicare |
$4.25
|
|
|
DOXAPRAM HCL 20MG/ML MDV 6X20ML
|
Facility
|
IP
|
$7.73
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
4400254
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.48 |
| Max. Negotiated Rate |
$5.02 |
| Rate for Payer: Aetna of NY Commercial |
$4.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$3.48
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$3.48
|
| Rate for Payer: Cash Price |
$5.80
|
| Rate for Payer: Galaxy Health Commercial |
$5.02
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$4.25
|
| Rate for Payer: WellCare Medicare |
$4.25
|
|
|
DOXAZOSIN MESYLATE 2MG TABS 100 EA
|
Facility
|
OP
|
$11.59
|
|
|
Service Code
|
NDC 51079095820
|
| Hospital Charge Code |
4400256
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.94 |
| Max. Negotiated Rate |
$9.33 |
| Rate for Payer: Aetna of NY Commercial |
$8.11
|
| Rate for Payer: Aetna of NY Medicare |
$5.33
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$8.69
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$8.69
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$4.29
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$5.80
|
| Rate for Payer: Cash Price |
$8.69
|
| Rate for Payer: CDPHP Commercial |
$9.33
|
| Rate for Payer: CDPHP Medicare |
$4.29
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$9.27
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$9.27
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$9.27
|
| Rate for Payer: EmblemHealth Medicaid |
$9.27
|
| Rate for Payer: EmblemHealth Medicare |
$3.94
|
| Rate for Payer: EmblemHealth Select Care |
$8.34
|
| Rate for Payer: Fidelis Medicare |
$4.42
|
| Rate for Payer: Galaxy Health Commercial |
$7.53
|
| Rate for Payer: Hamaspik Choice Medicare |
$4.29
|
| Rate for Payer: Humana Medicare |
$4.29
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$8.11
|
| Rate for Payer: Local 1199SEIU Medicare |
$5.33
|
| Rate for Payer: MVP Health Care of NY Commercial |
$8.69
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$6.53
|
| Rate for Payer: MVP Health Care of NY Medicare |
$4.50
|
| Rate for Payer: United Healthcare Medicare |
$4.29
|
| Rate for Payer: WellCare Medicare |
$6.37
|
|
|
DOXAZOSIN MESYLATE 2MG TABS 100 EA
|
Facility
|
IP
|
$11.59
|
|
|
Service Code
|
NDC 51079095820
|
| Hospital Charge Code |
4400256
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.37 |
| Max. Negotiated Rate |
$7.53 |
| Rate for Payer: Cash Price |
$8.69
|
| Rate for Payer: Galaxy Health Commercial |
$7.53
|
| Rate for Payer: WellCare Medicare |
$6.37
|
|
|
DOXEPIN 25 MG CAPSULE 25 mg, 100 eaches
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
NDC 51079043720
|
| Hospital Charge Code |
4401308
|
|
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
|
|
|
DOXEPIN 25 MG CAPSULE 25 mg, 100 eaches
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
NDC 51079043720
|
| Hospital Charge Code |
4401308
|
|
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
|
|
|
DOXEPIN 50 MG CAPSULES
|
Facility
|
OP
|
$6.18
|
|
|
Service Code
|
NDC 51079043820
|
| Hospital Charge Code |
4409085
|
|
Hospital Revenue Code
|
270
|
| 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
|
|
|
DOXEPIN 50 MG CAPSULES
|
Facility
|
IP
|
$6.18
|
|
|
Service Code
|
NDC 51079043820
|
| Hospital Charge Code |
4409085
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$4.02 |
| Max. Negotiated Rate |
$4.02 |
| Rate for Payer: Cash Price |
$4.64
|
| Rate for Payer: Galaxy Health Commercial |
$4.02
|
|
|
DOXYCYCLINE 100 MG
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
NDC 60687011811
|
| Hospital Charge Code |
4409125
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.12 |
| Max. Negotiated Rate |
$14.49 |
| Rate for Payer: Aetna of NY Commercial |
$12.60
|
| Rate for Payer: Aetna of NY Medicare |
$8.28
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$13.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$13.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$6.66
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$9.00
|
| Rate for Payer: Cash Price |
$13.50
|
| Rate for Payer: CDPHP Commercial |
$14.49
|
| Rate for Payer: CDPHP Medicare |
$6.66
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$14.40
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$14.40
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$14.40
|
| Rate for Payer: EmblemHealth Medicaid |
$14.40
|
| Rate for Payer: EmblemHealth Medicare |
$6.12
|
| Rate for Payer: EmblemHealth Select Care |
$12.96
|
| Rate for Payer: Fidelis Medicare |
$6.86
|
| Rate for Payer: Galaxy Health Commercial |
$11.70
|
| Rate for Payer: Hamaspik Choice Medicare |
$6.66
|
| Rate for Payer: Humana Medicare |
$6.66
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$12.60
|
| Rate for Payer: Local 1199SEIU Medicare |
$8.28
|
| Rate for Payer: MVP Health Care of NY Commercial |
$13.50
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$10.13
|
| Rate for Payer: MVP Health Care of NY Medicare |
$6.99
|
| Rate for Payer: United Healthcare Medicare |
$6.66
|
| Rate for Payer: WellCare Medicare |
$9.90
|
|
|
DOXYCYCLINE 100 MG
|
Facility
|
IP
|
$18.00
|
|
|
Service Code
|
NDC 60687011811
|
| Hospital Charge Code |
4409125
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.90 |
| Max. Negotiated Rate |
$11.70 |
| Rate for Payer: Cash Price |
$13.50
|
| Rate for Payer: Galaxy Health Commercial |
$11.70
|
| Rate for Payer: WellCare Medicare |
$9.90
|
|
|
DOXYCYCLINE HYCLATE 100MG PWVL 10X1EA
|
Facility
|
OP
|
$56.14
|
|
|
Service Code
|
NDC 63323013011
|
| Hospital Charge Code |
4400258
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.09 |
| Max. Negotiated Rate |
$45.19 |
| Rate for Payer: Aetna of NY Commercial |
$39.30
|
| Rate for Payer: Aetna of NY Medicare |
$25.82
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$42.10
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$42.10
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$20.77
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$28.07
|
| Rate for Payer: Cash Price |
$42.11
|
| Rate for Payer: CDPHP Commercial |
$45.19
|
| Rate for Payer: CDPHP Medicare |
$20.77
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$44.91
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$44.91
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$44.91
|
| Rate for Payer: EmblemHealth Medicaid |
$44.91
|
| Rate for Payer: EmblemHealth Medicare |
$19.09
|
| Rate for Payer: EmblemHealth Select Care |
$40.42
|
| Rate for Payer: Fidelis Medicare |
$21.39
|
| Rate for Payer: Galaxy Health Commercial |
$36.49
|
| Rate for Payer: Hamaspik Choice Medicare |
$20.77
|
| Rate for Payer: Humana Medicare |
$20.77
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$39.30
|
| Rate for Payer: Local 1199SEIU Medicare |
$25.82
|
| Rate for Payer: MVP Health Care of NY Commercial |
$42.10
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$31.61
|
| Rate for Payer: MVP Health Care of NY Medicare |
$21.81
|
| Rate for Payer: United Healthcare Medicare |
$20.77
|
| Rate for Payer: WellCare Medicare |
$30.88
|
|
|
DOXYCYCLINE HYCLATE 100MG PWVL 10X1EA
|
Facility
|
IP
|
$56.14
|
|
|
Service Code
|
NDC 63323013011
|
| Hospital Charge Code |
4400258
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$30.88 |
| Max. Negotiated Rate |
$36.49 |
| Rate for Payer: Cash Price |
$42.11
|
| Rate for Payer: Galaxy Health Commercial |
$36.49
|
| Rate for Payer: WellCare Medicare |
$30.88
|
|
|
DOXYCYCLINE HYCLATE 100MG TABS 10X10EA
|
Facility
|
OP
|
$6.00
|
|
| Hospital Charge Code |
4400259
|
|
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
|
|
|
DOXYCYCLINE HYCLATE 100MG TABS 10X10EA
|
Facility
|
IP
|
$6.00
|
|
| Hospital Charge Code |
4400259
|
|
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
|
|
|
DRAINAGE EXTERNAL AUDITORY CANAL ABSCESS
|
Facility
|
OP
|
$2,013.00
|
|
|
Service Code
|
HCPCS 69020
|
| Hospital Charge Code |
4602237
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$250.00 |
| Max. Negotiated Rate |
$1,620.46 |
| Rate for Payer: Aetna of NY Commercial |
$955.00
|
| Rate for Payer: Aetna of NY Medicare |
$925.98
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$950.93
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$1,189.18
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$744.81
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$1,006.50
|
| Rate for Payer: Cash Price |
$1,509.75
|
| Rate for Payer: Cash Price |
$1,509.75
|
| Rate for Payer: Cash Price |
$1,509.75
|
| Rate for Payer: Cash Price |
$1,509.75
|
| Rate for Payer: CDPHP Commercial |
$1,620.46
|
| Rate for Payer: CDPHP Medicare |
$744.81
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$1,182.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$1,610.40
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$1,610.40
|
| Rate for Payer: EmblemHealth Medicaid |
$1,610.40
|
| Rate for Payer: EmblemHealth Medicare |
$684.42
|
| Rate for Payer: EmblemHealth Select Care |
$1,064.00
|
| Rate for Payer: Fidelis Child Health Plus/Essential Plan/HARP/Medicaid |
$250.00
|
| Rate for Payer: Fidelis Medicare |
$767.15
|
| Rate for Payer: Galaxy Health Commercial |
$1,308.45
|
| Rate for Payer: Hamaspik Choice Medicare |
$744.81
|
| Rate for Payer: Humana Medicare |
$744.81
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$955.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$925.98
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,174.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$881.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$782.05
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$980.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$670.36
|
| Rate for Payer: United Healthcare Commercial |
$980.00
|
| Rate for Payer: United Healthcare Medicare |
$744.81
|
| Rate for Payer: WellCare Medicare |
$1,107.15
|
|
|
DRAINAGE EXTERNAL AUDITORY CANAL ABSCESS
|
Facility
|
IP
|
$2,013.00
|
|
|
Service Code
|
HCPCS 69020
|
| Hospital Charge Code |
4602237
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$1,308.45 |
| Max. Negotiated Rate |
$1,308.45 |
| Rate for Payer: Cash Price |
$1,509.75
|
| Rate for Payer: Galaxy Health Commercial |
$1,308.45
|
|
|
DRAINAGE EXTERNAL EAR ABSCESS/HEMATOMA CMPLX
|
Facility
|
IP
|
$4,500.00
|
|
|
Service Code
|
HCPCS 69005
|
| Hospital Charge Code |
4601207
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$2,925.00 |
| Max. Negotiated Rate |
$2,925.00 |
| Rate for Payer: Cash Price |
$3,375.00
|
| Rate for Payer: Galaxy Health Commercial |
$2,925.00
|
|
|
DRAINAGE EXTERNAL EAR ABSCESS/HEMATOMA CMPLX
|
Facility
|
OP
|
$4,500.00
|
|
|
Service Code
|
HCPCS 69005
|
| Hospital Charge Code |
4601207
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$250.00 |
| Max. Negotiated Rate |
$3,622.50 |
| Rate for Payer: Aetna of NY Commercial |
$955.00
|
| Rate for Payer: Aetna of NY Medicare |
$2,070.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$950.93
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$1,189.18
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$1,665.00
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$2,250.00
|
| Rate for Payer: Cash Price |
$3,375.00
|
| Rate for Payer: Cash Price |
$3,375.00
|
| Rate for Payer: Cash Price |
$3,375.00
|
| Rate for Payer: Cash Price |
$3,375.00
|
| Rate for Payer: CDPHP Commercial |
$3,622.50
|
| Rate for Payer: CDPHP Medicare |
$1,665.00
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$1,182.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$3,600.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$3,600.00
|
| Rate for Payer: EmblemHealth Medicaid |
$3,600.00
|
| Rate for Payer: EmblemHealth Medicare |
$1,530.00
|
| Rate for Payer: EmblemHealth Select Care |
$1,064.00
|
| Rate for Payer: Fidelis Child Health Plus/Essential Plan/HARP/Medicaid |
$250.00
|
| Rate for Payer: Fidelis Medicare |
$1,714.95
|
| Rate for Payer: Galaxy Health Commercial |
$2,925.00
|
| Rate for Payer: Hamaspik Choice Medicare |
$1,665.00
|
| Rate for Payer: Humana Medicare |
$1,665.00
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$955.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$2,070.00
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,174.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$881.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$1,748.25
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$980.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$1,544.75
|
| Rate for Payer: United Healthcare Commercial |
$980.00
|
| Rate for Payer: United Healthcare Medicare |
$1,665.00
|
| Rate for Payer: WellCare Medicare |
$2,475.00
|
|
|
DRAIN/INJ INTER JOINT/BURSA W/US
|
Facility
|
OP
|
$1,979.00
|
|
|
Service Code
|
HCPCS 20606
|
| Hospital Charge Code |
4852004
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$658.90 |
| Max. Negotiated Rate |
$2,521.93 |
| Rate for Payer: Aetna of NY Commercial |
$1,385.30
|
| Rate for Payer: Aetna of NY Medicare |
$910.34
|
| 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 |
$732.23
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$989.50
|
| Rate for Payer: Cash Price |
$1,484.25
|
| Rate for Payer: Cash Price |
$1,484.25
|
| Rate for Payer: Cash Price |
$1,484.25
|
| Rate for Payer: CDPHP Commercial |
$1,593.10
|
| Rate for Payer: CDPHP Medicare |
$732.23
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$1,583.20
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$1,583.20
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$1,583.20
|
| Rate for Payer: EmblemHealth Medicaid |
$1,583.20
|
| Rate for Payer: EmblemHealth Medicare |
$672.86
|
| Rate for Payer: EmblemHealth Select Care |
$1,424.88
|
| Rate for Payer: Fidelis Medicare |
$754.20
|
| Rate for Payer: Galaxy Health Commercial |
$1,286.35
|
| Rate for Payer: Hamaspik Choice Medicare |
$732.23
|
| Rate for Payer: Humana Medicare |
$732.23
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,385.30
|
| Rate for Payer: Local 1199SEIU Medicare |
$910.34
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,484.25
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$1,114.18
|
| Rate for Payer: MVP Health Care of NY Medicare |
$768.84
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$658.90
|
| Rate for Payer: United Healthcare Medicare |
$732.23
|
| Rate for Payer: WellCare Medicare |
$1,088.45
|
|
|
DRAIN/INJ INTER JOINT/BURSA W/US
|
Facility
|
IP
|
$1,979.00
|
|
|
Service Code
|
HCPCS 20606
|
| Hospital Charge Code |
4852004
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,286.35 |
| Max. Negotiated Rate |
$1,286.35 |
| Rate for Payer: Cash Price |
$1,484.25
|
| Rate for Payer: Galaxy Health Commercial |
$1,286.35
|
|
|
DRAIN/INJ INTERM JNT/BURSA
|
Facility
|
IP
|
$847.00
|
|
|
Service Code
|
HCPCS 20605
|
| Hospital Charge Code |
4856668
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$550.55 |
| Max. Negotiated Rate |
$550.55 |
| Rate for Payer: Cash Price |
$635.25
|
| Rate for Payer: Galaxy Health Commercial |
$550.55
|
|
|
DRAIN/INJ INTERM JNT/BURSA
|
Facility
|
OP
|
$847.00
|
|
|
Service Code
|
HCPCS 20605
|
| Hospital Charge Code |
4856668
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$282.20 |
| Max. Negotiated Rate |
$2,521.93 |
| Rate for Payer: Aetna of NY Commercial |
$592.90
|
| Rate for Payer: Aetna of NY Medicare |
$389.62
|
| 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 |
$313.39
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$423.50
|
| Rate for Payer: Cash Price |
$635.25
|
| Rate for Payer: Cash Price |
$635.25
|
| Rate for Payer: Cash Price |
$635.25
|
| Rate for Payer: CDPHP Commercial |
$681.84
|
| Rate for Payer: CDPHP Medicare |
$313.39
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$677.60
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$677.60
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$677.60
|
| Rate for Payer: EmblemHealth Medicaid |
$677.60
|
| Rate for Payer: EmblemHealth Medicare |
$287.98
|
| Rate for Payer: EmblemHealth Select Care |
$609.84
|
| Rate for Payer: Fidelis Medicare |
$322.79
|
| Rate for Payer: Galaxy Health Commercial |
$550.55
|
| Rate for Payer: Hamaspik Choice Medicare |
$313.39
|
| Rate for Payer: Humana Medicare |
$313.39
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$592.90
|
| Rate for Payer: Local 1199SEIU Medicare |
$389.62
|
| Rate for Payer: MVP Health Care of NY Commercial |
$635.25
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$476.86
|
| Rate for Payer: MVP Health Care of NY Medicare |
$329.06
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$282.20
|
| Rate for Payer: United Healthcare Medicare |
$313.39
|
| Rate for Payer: WellCare Medicare |
$465.85
|
|
