Ellenville Regional Hospital

All Charges

Charge

Type

Setting

Price

LEVALBUTEROL HCL 0.63MG/3ML AMIH 24X3ML

Facility

$6.18

Service Code	NDC 76204080011
Hospital Charge Code	4400815
Hospital Revenue Code	250
Min. Negotiated Rate	$0.93
Max. Negotiated Rate	$4.94
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) Medicare	$2.47
Rate for Payer: Cash Price	$4.64
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	$2.47
Rate for Payer: Galaxy Health Commercial	$4.02
Rate for Payer: Hamaspik Choice Medicare	$2.47
Rate for Payer: Humana Medicare	$2.47
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	$4.63
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$3.48
Rate for Payer: MVP Health Care of NY Medicare	$2.60
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$0.93
Rate for Payer: United Healthcare Medicare	$2.47
Rate for Payer: WellCare Medicare	$3.40

LEVALBUTEROL HCL 0.63MG/3ML AMIH 24X3ML

Facility

$6.18

Service Code	NDC 76204080011
Hospital Charge Code	4400815
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

LEVALBUTEROL HCL 1.25MG/3ML AMIH 24X3ML

Facility

$20.60

Service Code	NDC 76204090001
Hospital Charge Code	4400816
Hospital Revenue Code	250
Min. Negotiated Rate	$11.33
Max. Negotiated Rate	$13.39
Rate for Payer: Cash Price	$15.45
Rate for Payer: Galaxy Health Commercial	$13.39
Rate for Payer: WellCare Medicare	$11.33

LEVALBUTEROL HCL 1.25MG/3ML AMIH 24X3ML

Facility

$20.60

Service Code	NDC 76204090001
Hospital Charge Code	4400816
Hospital Revenue Code	250
Min. Negotiated Rate	$3.09
Max. Negotiated Rate	$16.48
Rate for Payer: Aetna of NY Commercial	$14.42
Rate for Payer: Aetna of NY Medicare	$9.48
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$8.24
Rate for Payer: Cash Price	$15.45
Rate for Payer: CDPHP Medicare	$7.62
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$16.48
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$16.48
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$16.48
Rate for Payer: EmblemHealth Medicaid	$16.48
Rate for Payer: EmblemHealth Medicare	$7.00
Rate for Payer: EmblemHealth Select Care	$14.83
Rate for Payer: Fidelis Medicare	$8.24
Rate for Payer: Galaxy Health Commercial	$13.39
Rate for Payer: Hamaspik Choice Medicare	$8.24
Rate for Payer: Humana Medicare	$8.24
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$14.42
Rate for Payer: Local 1199SEIU Medicare	$9.48
Rate for Payer: MVP Health Care of NY Commercial	$15.45
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$11.60
Rate for Payer: MVP Health Care of NY Medicare	$8.65
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$3.09
Rate for Payer: United Healthcare Medicare	$8.24
Rate for Payer: WellCare Medicare	$11.33

LEVETIRACETAM 100MG/ML SOLN 500 ML

Facility

$6.18

Service Code	NDC 50383024105
Hospital Charge Code	4400428
Hospital Revenue Code	250
Min. Negotiated Rate	$0.93
Max. Negotiated Rate	$4.94
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) Medicare	$2.47
Rate for Payer: Cash Price	$4.64
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	$2.47
Rate for Payer: Galaxy Health Commercial	$4.02
Rate for Payer: Hamaspik Choice Medicare	$2.47
Rate for Payer: Humana Medicare	$2.47
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	$4.63
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$3.48
Rate for Payer: MVP Health Care of NY Medicare	$2.60
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$0.93
Rate for Payer: United Healthcare Medicare	$2.47
Rate for Payer: WellCare Medicare	$3.40

LEVETIRACETAM 100MG/ML SOLN 500 ML

Facility

$6.18

Service Code	NDC 50383024105
Hospital Charge Code	4400428
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

LEVETIRACETAM 250MG TABS 10X10EA

Facility

$8.76

Service Code	NDC 904605161
Hospital Charge Code	4400429
Hospital Revenue Code	250
Min. Negotiated Rate	$4.82
Max. Negotiated Rate	$5.69
Rate for Payer: Cash Price	$6.57
Rate for Payer: Galaxy Health Commercial	$5.69
Rate for Payer: WellCare Medicare	$4.82

LEVETIRACETAM 250MG TABS 10X10EA

Facility

$8.76

Service Code	NDC 904605161
Hospital Charge Code	4400429
Hospital Revenue Code	250
Min. Negotiated Rate	$1.31
Max. Negotiated Rate	$7.01
Rate for Payer: Aetna of NY Commercial	$6.13
Rate for Payer: Aetna of NY Medicare	$4.03
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$3.50
Rate for Payer: Cash Price	$6.57
Rate for Payer: CDPHP Medicare	$3.24
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$7.01
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$7.01
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$7.01
Rate for Payer: EmblemHealth Medicaid	$7.01
Rate for Payer: EmblemHealth Medicare	$2.98
Rate for Payer: EmblemHealth Select Care	$6.31
Rate for Payer: Fidelis Medicare	$3.50
Rate for Payer: Galaxy Health Commercial	$5.69
Rate for Payer: Hamaspik Choice Medicare	$3.50
Rate for Payer: Humana Medicare	$3.50
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$6.13
Rate for Payer: Local 1199SEIU Medicare	$4.03
Rate for Payer: MVP Health Care of NY Commercial	$6.57
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$4.93
Rate for Payer: MVP Health Care of NY Medicare	$3.68
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$1.31
Rate for Payer: United Healthcare Medicare	$3.50
Rate for Payer: WellCare Medicare	$4.82

LEVETIRACETAM 500MG TABS 10X10EA

Facility

$10.82

Service Code	NDC 904605261
Hospital Charge Code	4400430
Hospital Revenue Code	250
Min. Negotiated Rate	$1.62
Max. Negotiated Rate	$8.66
Rate for Payer: Aetna of NY Commercial	$7.57
Rate for Payer: Aetna of NY Medicare	$4.98
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$4.33
Rate for Payer: Cash Price	$8.12
Rate for Payer: CDPHP Medicare	$4.00
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$8.66
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$8.66
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$8.66
Rate for Payer: EmblemHealth Medicaid	$8.66
Rate for Payer: EmblemHealth Medicare	$3.68
Rate for Payer: EmblemHealth Select Care	$7.79
Rate for Payer: Fidelis Medicare	$4.33
Rate for Payer: Galaxy Health Commercial	$7.03
Rate for Payer: Hamaspik Choice Medicare	$4.33
Rate for Payer: Humana Medicare	$4.33
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$7.57
Rate for Payer: Local 1199SEIU Medicare	$4.98
Rate for Payer: MVP Health Care of NY Commercial	$8.12
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$6.09
Rate for Payer: MVP Health Care of NY Medicare	$4.54
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$1.62
Rate for Payer: United Healthcare Medicare	$4.33
Rate for Payer: WellCare Medicare	$5.95

LEVETIRACETAM 500MG TABS 10X10EA

Facility

$10.82

Service Code	NDC 904605261
Hospital Charge Code	4400430
Hospital Revenue Code	250
Min. Negotiated Rate	$5.95
Max. Negotiated Rate	$7.03
Rate for Payer: Cash Price	$8.12
Rate for Payer: Galaxy Health Commercial	$7.03
Rate for Payer: WellCare Medicare	$5.95

LEVETIRACETAM INJECTION 10 MG

Facility

$0.48

Service Code	HCPCS J1953
Hospital Charge Code	4400431
Hospital Revenue Code	636
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.31
Rate for Payer: Aetna of NY Commercial	$0.26
Rate for Payer: Cash Price	$0.36
Rate for Payer: Cash Price	$0.36
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$0.03
Rate for Payer: EmblemHealth Select Care	$0.03
Rate for Payer: Galaxy Health Commercial	$0.31
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$0.26
Rate for Payer: WellCare Medicare	$0.26

LEVETIRACETAM INJECTION 10 MG

Facility

$0.48

Service Code	HCPCS J1953
Hospital Charge Code	4400431
Hospital Revenue Code	636
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.38
Rate for Payer: Aetna of NY Medicare	$0.22
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$0.19
Rate for Payer: Cash Price	$0.36
Rate for Payer: Cash Price	$0.36
Rate for Payer: CDPHP Medicare	$0.18
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$0.03
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$0.38
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$0.38
Rate for Payer: EmblemHealth Medicaid	$0.38
Rate for Payer: EmblemHealth Medicare	$0.16
Rate for Payer: EmblemHealth Select Care	$0.03
Rate for Payer: Fidelis Medicare	$0.19
Rate for Payer: Galaxy Health Commercial	$0.31
Rate for Payer: Hamaspik Choice Medicare	$0.19
Rate for Payer: Humana Medicare	$0.19
Rate for Payer: Local 1199SEIU Medicare	$0.22
Rate for Payer: MVP Health Care of NY Commercial	$0.36
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$0.27
Rate for Payer: MVP Health Care of NY Medicare	$0.20
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$0.12
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$0.07
Rate for Payer: United Healthcare Commercial	$0.12
Rate for Payer: United Healthcare Medicare	$0.19
Rate for Payer: WellCare Medicare	$0.26

levOCARNitine 1 G/10 ML SOLN 100 mg, 118 mL

Facility

$140.00

Service Code	NDC 70954013910
Hospital Charge Code	4401558
Hospital Revenue Code	250
Min. Negotiated Rate	$77.00
Max. Negotiated Rate	$91.00
Rate for Payer: Cash Price	$105.00
Rate for Payer: Galaxy Health Commercial	$91.00
Rate for Payer: WellCare Medicare	$77.00

levOCARNitine 1 G/10 ML SOLN 100 mg, 118 mL

Facility

$140.00

Service Code	NDC 70954013910
Hospital Charge Code	4401558
Hospital Revenue Code	250
Min. Negotiated Rate	$21.00
Max. Negotiated Rate	$112.00
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) Medicare	$56.00
Rate for Payer: Cash Price	$105.00
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	$56.00
Rate for Payer: Galaxy Health Commercial	$91.00
Rate for Payer: Hamaspik Choice Medicare	$56.00
Rate for Payer: Humana Medicare	$56.00
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	$58.80
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$21.00
Rate for Payer: United Healthcare Medicare	$56.00
Rate for Payer: WellCare Medicare	$77.00

LEVOFLOXACIN 250MG TABS 10X10EA

Facility

$26.78

Service Code	NDC 904635161
Hospital Charge Code	4400424
Hospital Revenue Code	250
Min. Negotiated Rate	$4.02
Max. Negotiated Rate	$21.42
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) Medicare	$10.71
Rate for Payer: Cash Price	$20.08
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	$10.71
Rate for Payer: Galaxy Health Commercial	$17.41
Rate for Payer: Hamaspik Choice Medicare	$10.71
Rate for Payer: Humana Medicare	$10.71
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	$20.09
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$15.08
Rate for Payer: MVP Health Care of NY Medicare	$11.25
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$4.02
Rate for Payer: United Healthcare Medicare	$10.71
Rate for Payer: WellCare Medicare	$14.73

LEVOFLOXACIN 250MG TABS 10X10EA

Facility

$26.78

Service Code	NDC 904635161
Hospital Charge Code	4400424
Hospital Revenue Code	250
Min. Negotiated Rate	$14.73
Max. Negotiated Rate	$17.41
Rate for Payer: Cash Price	$20.08
Rate for Payer: Galaxy Health Commercial	$17.41
Rate for Payer: WellCare Medicare	$14.73

LEVOFLOXACIN 500MG TABS 50 EA

Facility

$58.45

Service Code	NDC 904635261
Hospital Charge Code	4400425
Hospital Revenue Code	250
Min. Negotiated Rate	$8.77
Max. Negotiated Rate	$46.76
Rate for Payer: Aetna of NY Commercial	$40.91
Rate for Payer: Aetna of NY Medicare	$26.89
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$23.38
Rate for Payer: Cash Price	$43.84
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	$23.38
Rate for Payer: Galaxy Health Commercial	$37.99
Rate for Payer: Hamaspik Choice Medicare	$23.38
Rate for Payer: Humana Medicare	$23.38
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$40.91
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	$24.55
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$8.77
Rate for Payer: United Healthcare Medicare	$23.38
Rate for Payer: WellCare Medicare	$32.15

LEVOFLOXACIN 500MG TABS 50 EA

Facility

$58.45

Service Code	NDC 904635261
Hospital Charge Code	4400425
Hospital Revenue Code	250
Min. Negotiated Rate	$32.15
Max. Negotiated Rate	$37.99
Rate for Payer: Cash Price	$43.84
Rate for Payer: Galaxy Health Commercial	$37.99
Rate for Payer: WellCare Medicare	$32.15

LEVOFLOXACIN INJ, 250 MG

Facility

$26.78

Service Code	HCPCS J1956
Hospital Charge Code	4450008
Hospital Revenue Code	636
Min. Negotiated Rate	$2.16
Max. Negotiated Rate	$17.41
Rate for Payer: Aetna of NY Commercial	$14.73
Rate for Payer: Cash Price	$20.08
Rate for Payer: Cash Price	$20.08
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$2.16
Rate for Payer: EmblemHealth Select Care	$2.16
Rate for Payer: Galaxy Health Commercial	$17.41
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$14.73
Rate for Payer: WellCare Medicare	$14.73

LEVOFLOXACIN INJ, 250 MG

Facility

$25.49

Service Code	HCPCS J1956
Hospital Charge Code	4450009
Hospital Revenue Code	636
Min. Negotiated Rate	$2.16
Max. Negotiated Rate	$16.57
Rate for Payer: Aetna of NY Commercial	$14.02
Rate for Payer: Cash Price	$19.12
Rate for Payer: Cash Price	$19.12
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$2.16
Rate for Payer: EmblemHealth Select Care	$2.16
Rate for Payer: Galaxy Health Commercial	$16.57
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$14.02
Rate for Payer: WellCare Medicare	$14.02

LEVOFLOXACIN INJ, 250 MG

Facility

$25.49

Service Code	HCPCS J1956
Hospital Charge Code	4450009
Hospital Revenue Code	636
Min. Negotiated Rate	$1.52
Max. Negotiated Rate	$20.39
Rate for Payer: Aetna of NY Medicare	$11.73
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$10.20
Rate for Payer: Cash Price	$19.12
Rate for Payer: Cash Price	$19.12
Rate for Payer: CDPHP Medicare	$9.43
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$2.16
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	$2.16
Rate for Payer: Fidelis Medicare	$10.20
Rate for Payer: Galaxy Health Commercial	$16.57
Rate for Payer: Hamaspik Choice Medicare	$10.20
Rate for Payer: Humana Medicare	$10.20
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	$10.71
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$1.52
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$3.82
Rate for Payer: United Healthcare Commercial	$1.52
Rate for Payer: United Healthcare Medicare	$10.20
Rate for Payer: WellCare Medicare	$14.02

LEVOFLOXACIN INJ, 250 MG

Facility

$26.78

Service Code	HCPCS J1956
Hospital Charge Code	4450008
Hospital Revenue Code	636
Min. Negotiated Rate	$1.52
Max. Negotiated Rate	$21.42
Rate for Payer: Aetna of NY Medicare	$12.32
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$10.71
Rate for Payer: Cash Price	$20.08
Rate for Payer: Cash Price	$20.08
Rate for Payer: CDPHP Medicare	$9.91
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$2.16
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	$2.16
Rate for Payer: Fidelis Medicare	$10.71
Rate for Payer: Galaxy Health Commercial	$17.41
Rate for Payer: Hamaspik Choice Medicare	$10.71
Rate for Payer: Humana Medicare	$10.71
Rate for Payer: Local 1199SEIU Medicare	$12.32
Rate for Payer: MVP Health Care of NY Commercial	$20.09
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$15.08
Rate for Payer: MVP Health Care of NY Medicare	$11.25
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$1.52
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$4.02
Rate for Payer: United Healthcare Commercial	$1.52
Rate for Payer: United Healthcare Medicare	$10.71
Rate for Payer: WellCare Medicare	$14.73

LEVOFLOXACIN INJ, 750 MG

Facility

$16.22

Service Code	HCPCS J1956
Hospital Charge Code	4450010
Hospital Revenue Code	636
Min. Negotiated Rate	$2.16
Max. Negotiated Rate	$10.54
Rate for Payer: Aetna of NY Commercial	$8.92
Rate for Payer: Cash Price	$12.16
Rate for Payer: Cash Price	$12.16
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$2.16
Rate for Payer: EmblemHealth Select Care	$2.16
Rate for Payer: Galaxy Health Commercial	$10.54
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$8.92
Rate for Payer: WellCare Medicare	$8.92

LEVOFLOXACIN INJ, 750 MG

Facility

$16.22

Service Code	HCPCS J1956
Hospital Charge Code	4450010
Hospital Revenue Code	636
Min. Negotiated Rate	$1.52
Max. Negotiated Rate	$12.98
Rate for Payer: Aetna of NY Medicare	$7.46
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$6.49
Rate for Payer: Cash Price	$12.16
Rate for Payer: Cash Price	$12.16
Rate for Payer: CDPHP Medicare	$6.00
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$2.16
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	$2.16
Rate for Payer: Fidelis Medicare	$6.49
Rate for Payer: Galaxy Health Commercial	$10.54
Rate for Payer: Hamaspik Choice Medicare	$6.49
Rate for Payer: Humana Medicare	$6.49
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	$6.81
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$1.52
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$2.43
Rate for Payer: United Healthcare Commercial	$1.52
Rate for Payer: United Healthcare Medicare	$6.49
Rate for Payer: WellCare Medicare	$8.92

levothyroxine 100 MCG TABLET 100 mcg, 100 eaches

Facility

$17.00

Service Code	NDC 51079044201
Hospital Charge Code	4400853
Hospital Revenue Code	250
Min. Negotiated Rate	$9.35
Max. Negotiated Rate	$11.05
Rate for Payer: Cash Price	$12.75
Rate for Payer: Galaxy Health Commercial	$11.05
Rate for Payer: WellCare Medicare	$9.35

Know your out-of-pocket cost for care.

All Charges