|
levOCARNitine 1 G/10 ML SOLN 100 mg, 118 mL
|
Facility
OP
|
$140.00
|
|
| Hospital Charge Code |
4401558
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$47.60 |
| Max. Negotiated Rate |
$112.70 |
| Rate for Payer: Aetna of NY Commercial |
$98.00
|
| Rate for Payer: Aetna of NY Medicare |
$64.40
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$105.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$105.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$51.80
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$70.00
|
| Rate for Payer: Cash Price |
$105.00
|
| Rate for Payer: CDPHP Commercial |
$112.70
|
| Rate for Payer: CDPHP Medicare |
$51.80
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$112.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$112.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$112.00
|
| Rate for Payer: EmblemHealth Medicaid |
$112.00
|
| Rate for Payer: EmblemHealth Medicare |
$47.60
|
| Rate for Payer: EmblemHealth Select Care |
$100.80
|
| Rate for Payer: Fidelis Medicare |
$53.35
|
| Rate for Payer: Galaxy Health Commercial |
$91.00
|
| Rate for Payer: Hamaspik Choice Medicare |
$51.80
|
| Rate for Payer: Humana Medicare |
$51.80
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$98.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$64.40
|
| Rate for Payer: MVP Health Care of NY Commercial |
$105.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$78.82
|
| Rate for Payer: MVP Health Care of NY Medicare |
$54.39
|
| Rate for Payer: United Healthcare Medicare |
$51.80
|
| Rate for Payer: WellCare Medicare |
$77.00
|
|
|
LEVOFLOXACIN 250MG TABS 10X10EA
|
Facility
OP
|
$26.78
|
|
| Hospital Charge Code |
4400424
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.11 |
| Max. Negotiated Rate |
$21.56 |
| Rate for Payer: Aetna of NY Commercial |
$18.75
|
| Rate for Payer: Aetna of NY Medicare |
$12.32
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$20.08
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$20.08
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$9.91
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$13.39
|
| Rate for Payer: Cash Price |
$20.09
|
| Rate for Payer: CDPHP Commercial |
$21.56
|
| Rate for Payer: CDPHP Medicare |
$9.91
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$21.42
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$21.42
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$21.42
|
| Rate for Payer: EmblemHealth Medicaid |
$21.42
|
| Rate for Payer: EmblemHealth Medicare |
$9.11
|
| Rate for Payer: EmblemHealth Select Care |
$19.28
|
| Rate for Payer: Fidelis Medicare |
$10.21
|
| Rate for Payer: Galaxy Health Commercial |
$17.41
|
| Rate for Payer: Hamaspik Choice Medicare |
$9.91
|
| Rate for Payer: Humana Medicare |
$9.91
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$18.75
|
| Rate for Payer: Local 1199SEIU Medicare |
$12.32
|
| Rate for Payer: MVP Health Care of NY Commercial |
$20.08
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$15.08
|
| Rate for Payer: MVP Health Care of NY Medicare |
$10.40
|
| Rate for Payer: United Healthcare Medicare |
$9.91
|
| Rate for Payer: WellCare Medicare |
$14.73
|
|
|
LEVOFLOXACIN 500MG TABS 50 EA
|
Facility
OP
|
$58.45
|
|
| Hospital Charge Code |
4400425
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.87 |
| Max. Negotiated Rate |
$47.05 |
| Rate for Payer: Aetna of NY Commercial |
$40.92
|
| Rate for Payer: Aetna of NY Medicare |
$26.89
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$43.84
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$43.84
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$21.63
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$29.22
|
| Rate for Payer: Cash Price |
$43.84
|
| Rate for Payer: CDPHP Commercial |
$47.05
|
| Rate for Payer: CDPHP Medicare |
$21.63
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$46.76
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$46.76
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$46.76
|
| Rate for Payer: EmblemHealth Medicaid |
$46.76
|
| Rate for Payer: EmblemHealth Medicare |
$19.87
|
| Rate for Payer: EmblemHealth Select Care |
$42.08
|
| Rate for Payer: Fidelis Medicare |
$22.28
|
| Rate for Payer: Galaxy Health Commercial |
$37.99
|
| Rate for Payer: Hamaspik Choice Medicare |
$21.63
|
| Rate for Payer: Humana Medicare |
$21.63
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$40.92
|
| Rate for Payer: Local 1199SEIU Medicare |
$26.89
|
| Rate for Payer: MVP Health Care of NY Commercial |
$43.84
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$32.91
|
| Rate for Payer: MVP Health Care of NY Medicare |
$22.71
|
| Rate for Payer: United Healthcare Medicare |
$21.63
|
| Rate for Payer: WellCare Medicare |
$32.15
|
|
|
LEVOFLOXACIN INJ, 250 MG
|
Facility
OP
|
$26.78
|
|
|
Service Code
|
HCPCS J1956
|
| Hospital Charge Code |
4450008
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.96 |
| Max. Negotiated Rate |
$21.56 |
| Rate for Payer: Aetna of NY Commercial |
$14.73
|
| Rate for Payer: Aetna of NY Medicare |
$12.32
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$0.96
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$0.96
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$9.91
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$13.39
|
| Rate for Payer: Cash Price |
$20.09
|
| Rate for Payer: Cash Price |
$20.09
|
| Rate for Payer: CDPHP Commercial |
$21.56
|
| Rate for Payer: CDPHP Medicare |
$9.91
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$0.96
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$21.42
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$21.42
|
| Rate for Payer: EmblemHealth Medicaid |
$21.42
|
| Rate for Payer: EmblemHealth Medicare |
$9.11
|
| Rate for Payer: EmblemHealth Select Care |
$0.96
|
| Rate for Payer: Fidelis Medicare |
$10.21
|
| Rate for Payer: Galaxy Health Commercial |
$17.41
|
| Rate for Payer: Hamaspik Choice Medicare |
$9.91
|
| Rate for Payer: Humana Medicare |
$9.91
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$14.73
|
| Rate for Payer: Local 1199SEIU Medicare |
$12.32
|
| Rate for Payer: MVP Health Care of NY Commercial |
$20.08
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$15.08
|
| Rate for Payer: MVP Health Care of NY Medicare |
$10.40
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$1.52
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$0.96
|
| Rate for Payer: United Healthcare Commercial |
$1.52
|
| Rate for Payer: United Healthcare Medicare |
$9.91
|
| Rate for Payer: WellCare Medicare |
$14.73
|
|
|
LEVOFLOXACIN INJ, 250 MG
|
Facility
OP
|
$25.49
|
|
|
Service Code
|
HCPCS J1956
|
| Hospital Charge Code |
4450009
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.96 |
| Max. Negotiated Rate |
$20.52 |
| Rate for Payer: Aetna of NY Commercial |
$14.02
|
| Rate for Payer: Aetna of NY Medicare |
$11.73
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$0.96
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$0.96
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$9.43
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$12.74
|
| Rate for Payer: Cash Price |
$19.12
|
| Rate for Payer: Cash Price |
$19.12
|
| Rate for Payer: CDPHP Commercial |
$20.52
|
| Rate for Payer: CDPHP Medicare |
$9.43
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$0.96
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$20.39
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$20.39
|
| Rate for Payer: EmblemHealth Medicaid |
$20.39
|
| Rate for Payer: EmblemHealth Medicare |
$8.67
|
| Rate for Payer: EmblemHealth Select Care |
$0.96
|
| Rate for Payer: Fidelis Medicare |
$9.71
|
| Rate for Payer: Galaxy Health Commercial |
$16.57
|
| Rate for Payer: Hamaspik Choice Medicare |
$9.43
|
| Rate for Payer: Humana Medicare |
$9.43
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$14.02
|
| Rate for Payer: Local 1199SEIU Medicare |
$11.73
|
| Rate for Payer: MVP Health Care of NY Commercial |
$19.12
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$14.35
|
| Rate for Payer: MVP Health Care of NY Medicare |
$9.90
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$1.52
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$0.96
|
| Rate for Payer: United Healthcare Commercial |
$1.52
|
| Rate for Payer: United Healthcare Medicare |
$9.43
|
| Rate for Payer: WellCare Medicare |
$14.02
|
|
|
LEVOFLOXACIN INJ, 750 MG
|
Facility
OP
|
$16.22
|
|
|
Service Code
|
HCPCS J1956
|
| Hospital Charge Code |
4450010
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.96 |
| Max. Negotiated Rate |
$13.06 |
| Rate for Payer: Aetna of NY Commercial |
$8.92
|
| Rate for Payer: Aetna of NY Medicare |
$7.46
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$0.96
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$0.96
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$6.00
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$8.11
|
| Rate for Payer: Cash Price |
$12.16
|
| Rate for Payer: Cash Price |
$12.16
|
| Rate for Payer: CDPHP Commercial |
$13.06
|
| Rate for Payer: CDPHP Medicare |
$6.00
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$0.96
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$12.98
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$12.98
|
| Rate for Payer: EmblemHealth Medicaid |
$12.98
|
| Rate for Payer: EmblemHealth Medicare |
$5.51
|
| Rate for Payer: EmblemHealth Select Care |
$0.96
|
| Rate for Payer: Fidelis Medicare |
$6.18
|
| Rate for Payer: Galaxy Health Commercial |
$10.54
|
| Rate for Payer: Hamaspik Choice Medicare |
$6.00
|
| Rate for Payer: Humana Medicare |
$6.00
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$8.92
|
| Rate for Payer: Local 1199SEIU Medicare |
$7.46
|
| Rate for Payer: MVP Health Care of NY Commercial |
$12.16
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$9.13
|
| Rate for Payer: MVP Health Care of NY Medicare |
$6.30
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$1.52
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$0.96
|
| Rate for Payer: United Healthcare Commercial |
$1.52
|
| Rate for Payer: United Healthcare Medicare |
$6.00
|
| Rate for Payer: WellCare Medicare |
$8.92
|
|
|
levothyroxine 100 MCG TABLET 100 mcg, 100 eaches
|
Facility
OP
|
$17.00
|
|
| Hospital Charge Code |
4400853
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.78 |
| Max. Negotiated Rate |
$13.68 |
| Rate for Payer: Aetna of NY Commercial |
$11.90
|
| Rate for Payer: Aetna of NY Medicare |
$7.82
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$12.75
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$12.75
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$6.29
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$8.50
|
| Rate for Payer: Cash Price |
$12.75
|
| Rate for Payer: CDPHP Commercial |
$13.68
|
| Rate for Payer: CDPHP Medicare |
$6.29
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$13.60
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$13.60
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$13.60
|
| Rate for Payer: EmblemHealth Medicaid |
$13.60
|
| Rate for Payer: EmblemHealth Medicare |
$5.78
|
| Rate for Payer: EmblemHealth Select Care |
$12.24
|
| Rate for Payer: Fidelis Medicare |
$6.48
|
| Rate for Payer: Galaxy Health Commercial |
$11.05
|
| Rate for Payer: Hamaspik Choice Medicare |
$6.29
|
| Rate for Payer: Humana Medicare |
$6.29
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$11.90
|
| Rate for Payer: Local 1199SEIU Medicare |
$7.82
|
| Rate for Payer: MVP Health Care of NY Commercial |
$12.75
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$9.57
|
| Rate for Payer: MVP Health Care of NY Medicare |
$6.60
|
| Rate for Payer: United Healthcare Medicare |
$6.29
|
| Rate for Payer: WellCare Medicare |
$9.35
|
|
|
levothyroxine 112 MCG TABLET 112 mcg, 90 eaches
|
Facility
OP
|
$6.00
|
|
| Hospital Charge Code |
4401306
|
|
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
|
|
|
levothyroxine 125 MCG TABLET 125 mcg, 100 eaches
|
Facility
OP
|
$6.00
|
|
| Hospital Charge Code |
4401298
|
|
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
|
|
|
levothyroxine 137 MCG TABLET 137 mcg, 1 each
|
Facility
OP
|
$6.00
|
|
| Hospital Charge Code |
4401454
|
|
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
|
|
|
levothyroxine 50 MCG TABLET 50 mcg, 100 eaches
|
Facility
OP
|
$6.00
|
|
| Hospital Charge Code |
4401297
|
|
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
|
|
|
LEVOTHYROXINE 75 MCG TABLET
|
Facility
OP
|
$1.50
|
|
| Hospital Charge Code |
4401285
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$1.21 |
| Rate for Payer: Aetna of NY Commercial |
$1.05
|
| Rate for Payer: Aetna of NY Medicare |
$0.69
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$1.12
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$1.12
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$0.56
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$0.75
|
| Rate for Payer: Cash Price |
$1.12
|
| Rate for Payer: CDPHP Commercial |
$1.21
|
| Rate for Payer: CDPHP Medicare |
$0.56
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$1.20
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$1.20
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$1.20
|
| Rate for Payer: EmblemHealth Medicaid |
$1.20
|
| Rate for Payer: EmblemHealth Medicare |
$0.51
|
| Rate for Payer: EmblemHealth Select Care |
$1.08
|
| Rate for Payer: Fidelis Medicare |
$0.57
|
| Rate for Payer: Galaxy Health Commercial |
$0.98
|
| Rate for Payer: Hamaspik Choice Medicare |
$0.56
|
| Rate for Payer: Humana Medicare |
$0.56
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1.05
|
| Rate for Payer: Local 1199SEIU Medicare |
$0.69
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1.12
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$0.84
|
| Rate for Payer: MVP Health Care of NY Medicare |
$0.58
|
| Rate for Payer: United Healthcare Medicare |
$0.56
|
| Rate for Payer: WellCare Medicare |
$0.83
|
|
|
LEVOTHYROXINE 88 MCG TABLET
|
Facility
OP
|
$6.18
|
|
| Hospital Charge Code |
4401284
|
|
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
|
|
|
LEVOTHYROXINE SODIUM
|
Facility
OP
|
$6.00
|
|
| Hospital Charge Code |
4401286
|
|
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
|
|
|
LEXISCAN .1MG
|
Facility
OP
|
$188.00
|
|
|
Service Code
|
HCPCS J2785
|
| Hospital Charge Code |
4211246
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.05 |
| Max. Negotiated Rate |
$151.34 |
| Rate for Payer: Aetna of NY Commercial |
$103.40
|
| Rate for Payer: Aetna of NY Medicare |
$86.48
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$7.05
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$7.05
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$69.56
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$94.00
|
| Rate for Payer: Cash Price |
$141.00
|
| Rate for Payer: Cash Price |
$141.00
|
| Rate for Payer: CDPHP Commercial |
$151.34
|
| Rate for Payer: CDPHP Medicare |
$69.56
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$7.05
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$150.40
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$150.40
|
| Rate for Payer: EmblemHealth Medicaid |
$150.40
|
| Rate for Payer: EmblemHealth Medicare |
$63.92
|
| Rate for Payer: EmblemHealth Select Care |
$7.05
|
| Rate for Payer: Fidelis Medicare |
$71.65
|
| Rate for Payer: Galaxy Health Commercial |
$122.20
|
| Rate for Payer: Hamaspik Choice Medicare |
$69.56
|
| Rate for Payer: Humana Medicare |
$69.56
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$103.40
|
| Rate for Payer: Local 1199SEIU Medicare |
$86.48
|
| Rate for Payer: MVP Health Care of NY Commercial |
$141.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$105.84
|
| Rate for Payer: MVP Health Care of NY Medicare |
$73.04
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$102.76
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$7.05
|
| Rate for Payer: United Healthcare Commercial |
$102.76
|
| Rate for Payer: United Healthcare Medicare |
$69.56
|
| Rate for Payer: WellCare Medicare |
$103.40
|
|
|
LIALDA DR 1.2 GM TABLET 1.2 g, 120 eaches
|
Facility
OP
|
$34.00
|
|
| Hospital Charge Code |
4401434
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.56 |
| Max. Negotiated Rate |
$27.37 |
| Rate for Payer: Aetna of NY Commercial |
$23.80
|
| Rate for Payer: Aetna of NY Medicare |
$15.64
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$25.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$25.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$12.58
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$17.00
|
| Rate for Payer: Cash Price |
$25.50
|
| Rate for Payer: CDPHP Commercial |
$27.37
|
| Rate for Payer: CDPHP Medicare |
$12.58
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$27.20
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$27.20
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$27.20
|
| Rate for Payer: EmblemHealth Medicaid |
$27.20
|
| Rate for Payer: EmblemHealth Medicare |
$11.56
|
| Rate for Payer: EmblemHealth Select Care |
$24.48
|
| Rate for Payer: Fidelis Medicare |
$12.96
|
| Rate for Payer: Galaxy Health Commercial |
$22.10
|
| Rate for Payer: Hamaspik Choice Medicare |
$12.58
|
| Rate for Payer: Humana Medicare |
$12.58
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$23.80
|
| Rate for Payer: Local 1199SEIU Medicare |
$15.64
|
| Rate for Payer: MVP Health Care of NY Commercial |
$25.50
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$19.14
|
| Rate for Payer: MVP Health Care of NY Medicare |
$13.21
|
| Rate for Payer: United Healthcare Medicare |
$12.58
|
| Rate for Payer: WellCare Medicare |
$18.70
|
|
|
LIDOCAINE 0.05 OINT 35.44 GM
|
Facility
OP
|
$927.00
|
|
| Hospital Charge Code |
4400437
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$315.18 |
| Max. Negotiated Rate |
$746.24 |
| Rate for Payer: Aetna of NY Commercial |
$648.90
|
| Rate for Payer: Aetna of NY Medicare |
$426.42
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$695.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$695.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$342.99
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$463.50
|
| Rate for Payer: Cash Price |
$695.25
|
| Rate for Payer: CDPHP Commercial |
$746.24
|
| Rate for Payer: CDPHP Medicare |
$342.99
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$741.60
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$741.60
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$741.60
|
| Rate for Payer: EmblemHealth Medicaid |
$741.60
|
| Rate for Payer: EmblemHealth Medicare |
$315.18
|
| Rate for Payer: EmblemHealth Select Care |
$667.44
|
| Rate for Payer: Fidelis Medicare |
$353.28
|
| Rate for Payer: Galaxy Health Commercial |
$602.55
|
| Rate for Payer: Hamaspik Choice Medicare |
$342.99
|
| Rate for Payer: Humana Medicare |
$342.99
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$648.90
|
| Rate for Payer: Local 1199SEIU Medicare |
$426.42
|
| Rate for Payer: MVP Health Care of NY Commercial |
$695.25
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$521.90
|
| Rate for Payer: MVP Health Care of NY Medicare |
$360.14
|
| Rate for Payer: United Healthcare Medicare |
$342.99
|
| Rate for Payer: WellCare Medicare |
$509.85
|
|
|
LIDOCAINE 0.05 PTCH 30 EA
|
Facility
OP
|
$44.03
|
|
| Hospital Charge Code |
4400451
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.97 |
| Max. Negotiated Rate |
$35.44 |
| Rate for Payer: Aetna of NY Commercial |
$30.82
|
| Rate for Payer: Aetna of NY Medicare |
$20.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$33.02
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$33.02
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$16.29
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$22.02
|
| Rate for Payer: Cash Price |
$33.02
|
| Rate for Payer: CDPHP Commercial |
$35.44
|
| Rate for Payer: CDPHP Medicare |
$16.29
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$35.22
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$35.22
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$35.22
|
| Rate for Payer: EmblemHealth Medicaid |
$35.22
|
| Rate for Payer: EmblemHealth Medicare |
$14.97
|
| Rate for Payer: EmblemHealth Select Care |
$31.70
|
| Rate for Payer: Fidelis Medicare |
$16.78
|
| Rate for Payer: Galaxy Health Commercial |
$28.62
|
| Rate for Payer: Hamaspik Choice Medicare |
$16.29
|
| Rate for Payer: Humana Medicare |
$16.29
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$30.82
|
| Rate for Payer: Local 1199SEIU Medicare |
$20.25
|
| Rate for Payer: MVP Health Care of NY Commercial |
$33.02
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$24.79
|
| Rate for Payer: MVP Health Care of NY Medicare |
$17.11
|
| Rate for Payer: United Healthcare Medicare |
$16.29
|
| Rate for Payer: WellCare Medicare |
$24.22
|
|
|
LIDOCAINE 4% CREAM 4 g, 15 g
|
Facility
OP
|
$30.00
|
|
| Hospital Charge Code |
4401918
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.20 |
| Max. Negotiated Rate |
$24.15 |
| Rate for Payer: Aetna of NY Commercial |
$21.00
|
| Rate for Payer: Aetna of NY Medicare |
$13.80
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$22.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$22.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$11.10
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$15.00
|
| Rate for Payer: Cash Price |
$22.50
|
| Rate for Payer: CDPHP Commercial |
$24.15
|
| Rate for Payer: CDPHP Medicare |
$11.10
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$24.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$24.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$24.00
|
| Rate for Payer: EmblemHealth Medicaid |
$24.00
|
| Rate for Payer: EmblemHealth Medicare |
$10.20
|
| Rate for Payer: EmblemHealth Select Care |
$21.60
|
| Rate for Payer: Fidelis Medicare |
$11.43
|
| Rate for Payer: Galaxy Health Commercial |
$19.50
|
| Rate for Payer: Hamaspik Choice Medicare |
$11.10
|
| Rate for Payer: Humana Medicare |
$11.10
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$21.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$13.80
|
| Rate for Payer: MVP Health Care of NY Commercial |
$22.50
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$16.89
|
| Rate for Payer: MVP Health Care of NY Medicare |
$11.66
|
| Rate for Payer: United Healthcare Medicare |
$11.10
|
| Rate for Payer: WellCare Medicare |
$16.50
|
|
|
LIDOCAINE/EPINEPHRINE 1-0.001% MDV 25X20
|
Facility
OP
|
$7.98
|
|
| Hospital Charge Code |
4400448
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.71 |
| Max. Negotiated Rate |
$6.42 |
| Rate for Payer: Aetna of NY Commercial |
$5.59
|
| Rate for Payer: Aetna of NY Medicare |
$3.67
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$5.98
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$5.98
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$2.95
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$3.99
|
| Rate for Payer: Cash Price |
$5.98
|
| Rate for Payer: CDPHP Commercial |
$6.42
|
| Rate for Payer: CDPHP Medicare |
$2.95
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$6.38
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$6.38
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$6.38
|
| Rate for Payer: EmblemHealth Medicaid |
$6.38
|
| Rate for Payer: EmblemHealth Medicare |
$2.71
|
| Rate for Payer: EmblemHealth Select Care |
$5.75
|
| Rate for Payer: Fidelis Medicare |
$3.04
|
| Rate for Payer: Galaxy Health Commercial |
$5.19
|
| Rate for Payer: Hamaspik Choice Medicare |
$2.95
|
| Rate for Payer: Humana Medicare |
$2.95
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$5.59
|
| Rate for Payer: Local 1199SEIU Medicare |
$3.67
|
| Rate for Payer: MVP Health Care of NY Commercial |
$5.98
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$4.49
|
| Rate for Payer: MVP Health Care of NY Medicare |
$3.10
|
| Rate for Payer: United Healthcare Medicare |
$2.95
|
| Rate for Payer: WellCare Medicare |
$4.39
|
|
|
LIDOCAINE/EPINEPHRINE 2-0.001% MDV 25X30
|
Facility
OP
|
$6.18
|
|
| Hospital Charge Code |
4400449
|
|
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
|
|
|
LIDOCAINE HCL 1% VIAL 10 mg, 10 mL
|
Facility
OP
|
$8.00
|
|
| Hospital Charge Code |
4401926
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.72 |
| Max. Negotiated Rate |
$6.44 |
| Rate for Payer: Aetna of NY Commercial |
$5.60
|
| Rate for Payer: Aetna of NY Medicare |
$3.68
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$6.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$6.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$2.96
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$4.00
|
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: CDPHP Commercial |
$6.44
|
| Rate for Payer: CDPHP Medicare |
$2.96
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$6.40
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$6.40
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$6.40
|
| Rate for Payer: EmblemHealth Medicaid |
$6.40
|
| Rate for Payer: EmblemHealth Medicare |
$2.72
|
| Rate for Payer: EmblemHealth Select Care |
$5.76
|
| Rate for Payer: Fidelis Medicare |
$3.05
|
| Rate for Payer: Galaxy Health Commercial |
$5.20
|
| Rate for Payer: Hamaspik Choice Medicare |
$2.96
|
| Rate for Payer: Humana Medicare |
$2.96
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$5.60
|
| Rate for Payer: Local 1199SEIU Medicare |
$3.68
|
| Rate for Payer: MVP Health Care of NY Commercial |
$6.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$4.50
|
| Rate for Payer: MVP Health Care of NY Medicare |
$3.11
|
| Rate for Payer: United Healthcare Medicare |
$2.96
|
| Rate for Payer: WellCare Medicare |
$4.40
|
|
|
LIDOCAINE HCL 1% VIAL 10 mg, 20 mL
|
Facility
OP
|
$14.00
|
|
| Hospital Charge Code |
4401925
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.76 |
| Max. Negotiated Rate |
$11.27 |
| Rate for Payer: Aetna of NY Commercial |
$9.80
|
| Rate for Payer: Aetna of NY Medicare |
$6.44
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$10.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$10.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$5.18
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$7.00
|
| Rate for Payer: Cash Price |
$10.50
|
| Rate for Payer: CDPHP Commercial |
$11.27
|
| Rate for Payer: CDPHP Medicare |
$5.18
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$11.20
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$11.20
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$11.20
|
| Rate for Payer: EmblemHealth Medicaid |
$11.20
|
| Rate for Payer: EmblemHealth Medicare |
$4.76
|
| Rate for Payer: EmblemHealth Select Care |
$10.08
|
| Rate for Payer: Fidelis Medicare |
$5.34
|
| Rate for Payer: Galaxy Health Commercial |
$9.10
|
| Rate for Payer: Hamaspik Choice Medicare |
$5.18
|
| Rate for Payer: Humana Medicare |
$5.18
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$9.80
|
| Rate for Payer: Local 1199SEIU Medicare |
$6.44
|
| Rate for Payer: MVP Health Care of NY Commercial |
$10.50
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$7.88
|
| Rate for Payer: MVP Health Care of NY Medicare |
$5.44
|
| Rate for Payer: United Healthcare Medicare |
$5.18
|
| Rate for Payer: WellCare Medicare |
$7.70
|
|
|
LIDOCAINE HCL 1% VIAL 10 mg, 20 mL
|
Facility
OP
|
$6.00
|
|
| Hospital Charge Code |
4401923
|
|
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
|
|
|
LIDOCAINE HCL 1% VIAL 10 mg, 50 mL
|
Facility
OP
|
$11.00
|
|
| Hospital Charge Code |
4401924
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.74 |
| Max. Negotiated Rate |
$8.86 |
| Rate for Payer: Aetna of NY Commercial |
$7.70
|
| Rate for Payer: Aetna of NY Medicare |
$5.06
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$8.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$8.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$4.07
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$5.50
|
| Rate for Payer: Cash Price |
$8.25
|
| Rate for Payer: CDPHP Commercial |
$8.86
|
| Rate for Payer: CDPHP Medicare |
$4.07
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$8.80
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$8.80
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$8.80
|
| Rate for Payer: EmblemHealth Medicaid |
$8.80
|
| Rate for Payer: EmblemHealth Medicare |
$3.74
|
| Rate for Payer: EmblemHealth Select Care |
$7.92
|
| Rate for Payer: Fidelis Medicare |
$4.19
|
| Rate for Payer: Galaxy Health Commercial |
$7.15
|
| Rate for Payer: Hamaspik Choice Medicare |
$4.07
|
| Rate for Payer: Humana Medicare |
$4.07
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$7.70
|
| Rate for Payer: Local 1199SEIU Medicare |
$5.06
|
| Rate for Payer: MVP Health Care of NY Commercial |
$8.25
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$6.19
|
| Rate for Payer: MVP Health Care of NY Medicare |
$4.27
|
| Rate for Payer: United Healthcare Medicare |
$4.07
|
| Rate for Payer: WellCare Medicare |
$6.05
|
|
