Ellenville Regional Hospital

All Charges

Charge

Type

Setting

Price

METOPROLOL TARTRATE 100MG TABS 100 EA

Facility

$6.18

Service Code	NDC 51079080220
Hospital Charge Code	4400507
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

METOPROLOL TARTRATE 1MG/ML AMPS 12X5ML

Facility

$9.50

Service Code	NDC 63323066005
Hospital Charge Code	4400508
Hospital Revenue Code	250
Min. Negotiated Rate	$5.22
Max. Negotiated Rate	$6.17
Rate for Payer: Cash Price	$7.12
Rate for Payer: Galaxy Health Commercial	$6.17
Rate for Payer: WellCare Medicare	$5.22

METOPROLOL TARTRATE 1MG/ML AMPS 12X5ML

Facility

$9.50

Service Code	NDC 63323066005
Hospital Charge Code	4400508
Hospital Revenue Code	250
Min. Negotiated Rate	$1.43
Max. Negotiated Rate	$7.60
Rate for Payer: Aetna of NY Commercial	$6.65
Rate for Payer: Aetna of NY Medicare	$4.37
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$3.80
Rate for Payer: Cash Price	$7.12
Rate for Payer: CDPHP Medicare	$3.52
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$7.60
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$7.60
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$7.60
Rate for Payer: EmblemHealth Medicaid	$7.60
Rate for Payer: EmblemHealth Medicare	$3.23
Rate for Payer: EmblemHealth Select Care	$6.84
Rate for Payer: Fidelis Medicare	$3.80
Rate for Payer: Galaxy Health Commercial	$6.17
Rate for Payer: Hamaspik Choice Medicare	$3.80
Rate for Payer: Humana Medicare	$3.80
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$6.65
Rate for Payer: Local 1199SEIU Medicare	$4.37
Rate for Payer: MVP Health Care of NY Commercial	$7.12
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$5.35
Rate for Payer: MVP Health Care of NY Medicare	$3.99
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$1.43
Rate for Payer: United Healthcare Medicare	$3.80
Rate for Payer: WellCare Medicare	$5.22

METOPROLOL TARTRATE 25MG TABS 10X10EA

Facility

$6.18

Service Code	NDC 62584026501
Hospital Charge Code	4400510
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

METOPROLOL TARTRATE 25MG TABS 10X10EA

Facility

$6.18

Service Code	NDC 62584026501
Hospital Charge Code	4400510
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

METOPROLOL TARTRATE 50MG TABS 100 EA

Facility

$6.18

Service Code	NDC 51079080120
Hospital Charge Code	4400511
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

METOPROLOL TARTRATE 50MG TABS 100 EA

Facility

$6.18

Service Code	NDC 51079080120
Hospital Charge Code	4400511
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

METRONIDAZOLE 10 MG INJ

Facility

$0.12

Service Code	HCPCS J1836
Hospital Charge Code	4408963
Hospital Revenue Code	636
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.08
Rate for Payer: Aetna of NY Commercial	$0.07
Rate for Payer: Cash Price	$0.09
Rate for Payer: Cash Price	$0.09
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	$0.08
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$0.07
Rate for Payer: WellCare Medicare	$0.07

METRONIDAZOLE 10 MG INJ

Facility

$0.12

Service Code	HCPCS J1836
Hospital Charge Code	4408963
Hospital Revenue Code	636
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.10
Rate for Payer: Aetna of NY Medicare	$0.06
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$0.05
Rate for Payer: Cash Price	$0.09
Rate for Payer: Cash Price	$0.09
Rate for Payer: CDPHP Medicare	$0.04
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$0.03
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$0.10
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$0.10
Rate for Payer: EmblemHealth Medicaid	$0.10
Rate for Payer: EmblemHealth Medicare	$0.04
Rate for Payer: EmblemHealth Select Care	$0.03
Rate for Payer: Fidelis Medicare	$0.05
Rate for Payer: Galaxy Health Commercial	$0.08
Rate for Payer: Hamaspik Choice Medicare	$0.05
Rate for Payer: Humana Medicare	$0.05
Rate for Payer: Local 1199SEIU Medicare	$0.06
Rate for Payer: MVP Health Care of NY Commercial	$0.09
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$0.07
Rate for Payer: MVP Health Care of NY Medicare	$0.05
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$0.03
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$0.02
Rate for Payer: United Healthcare Commercial	$0.03
Rate for Payer: United Healthcare Medicare	$0.05
Rate for Payer: WellCare Medicare	$0.07

METRONIDAZOLE 250MG TABS 100 EA

Facility

$6.18

Service Code	NDC 904145361
Hospital Charge Code	4400512
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

METRONIDAZOLE 250MG TABS 100 EA

Facility

$6.18

Service Code	NDC 904145361
Hospital Charge Code	4400512
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

METRONIDAZOLE 500MG TABS 100 EA

Facility

$6.18

Service Code	NDC 42292000101
Hospital Charge Code	4400513
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

METRONIDAZOLE 500MG TABS 100 EA

Facility

$6.18

Service Code	NDC 42292000101
Hospital Charge Code	4400513
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

MEXILETINE 150 MG CAPSULE

Facility

$7.73

Service Code	NDC 93873901
Hospital Charge Code	4400838
Hospital Revenue Code	250
Min. Negotiated Rate	$1.16
Max. Negotiated Rate	$6.18
Rate for Payer: Aetna of NY Commercial	$5.41
Rate for Payer: Aetna of NY Medicare	$3.56
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$3.09
Rate for Payer: Cash Price	$5.80
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	$3.09
Rate for Payer: Galaxy Health Commercial	$5.02
Rate for Payer: Hamaspik Choice Medicare	$3.09
Rate for Payer: Humana Medicare	$3.09
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$5.41
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	$3.25
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$1.16
Rate for Payer: United Healthcare Medicare	$3.09
Rate for Payer: WellCare Medicare	$4.25

MEXILETINE 150 MG CAPSULE

Facility

$7.73

Service Code	NDC 93873901
Hospital Charge Code	4400838
Hospital Revenue Code	250
Min. Negotiated Rate	$4.25
Max. Negotiated Rate	$5.02
Rate for Payer: Cash Price	$5.80
Rate for Payer: Galaxy Health Commercial	$5.02
Rate for Payer: WellCare Medicare	$4.25

MICROALBUMIN URINE

Facility

$17.00

Service Code	HCPCS 82043
Hospital Charge Code	4300563
Hospital Revenue Code	300
Min. Negotiated Rate	$11.05
Max. Negotiated Rate	$11.05
Rate for Payer: Cash Price	$12.75
Rate for Payer: Galaxy Health Commercial	$11.05

MICROALBUMIN URINE

Facility

$17.00

Service Code	HCPCS 82043
Hospital Charge Code	4300563
Hospital Revenue Code	300
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$13.60
Rate for Payer: Aetna of NY Commercial	$11.05
Rate for Payer: Aetna of NY Medicare	$7.82
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$6.80
Rate for Payer: Cash Price	$12.75
Rate for Payer: CDPHP Medicare	$6.29
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$10.20
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	$10.20
Rate for Payer: Fidelis Medicare	$6.80
Rate for Payer: Galaxy Health Commercial	$11.05
Rate for Payer: Hamaspik Choice Medicare	$6.80
Rate for Payer: Humana Medicare	$6.80
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$11.05
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	$7.14
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$12.75
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$2.55
Rate for Payer: United Healthcare Commercial	$12.75
Rate for Payer: United Healthcare Medicare	$6.80
Rate for Payer: WellCare Medicare	$9.35

MICROPUNCTURE INTRODUCER SET

Facility

$139.05

Service Code	HCPCS C1894
Hospital Charge Code	4471876
Hospital Revenue Code	272
Min. Negotiated Rate	$90.38
Max. Negotiated Rate	$90.38
Rate for Payer: Cash Price	$104.29
Rate for Payer: Galaxy Health Commercial	$90.38

MICROPUNCTURE INTRODUCER SET

Facility

$139.05

Service Code	HCPCS C1894
Hospital Charge Code	4471876
Hospital Revenue Code	272
Min. Negotiated Rate	$20.86
Max. Negotiated Rate	$111.24
Rate for Payer: Aetna of NY Commercial	$97.33
Rate for Payer: Aetna of NY Medicare	$63.96
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$55.62
Rate for Payer: Cash Price	$104.29
Rate for Payer: CDPHP Medicare	$51.45
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$111.24
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$111.24
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$111.24
Rate for Payer: EmblemHealth Medicaid	$111.24
Rate for Payer: EmblemHealth Medicare	$47.28
Rate for Payer: EmblemHealth Select Care	$100.12
Rate for Payer: Fidelis Medicare	$55.62
Rate for Payer: Galaxy Health Commercial	$90.38
Rate for Payer: Hamaspik Choice Medicare	$55.62
Rate for Payer: Humana Medicare	$55.62
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$97.33
Rate for Payer: Local 1199SEIU Medicare	$63.96
Rate for Payer: MVP Health Care of NY Commercial	$104.29
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$78.29
Rate for Payer: MVP Health Care of NY Medicare	$58.40
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$20.86
Rate for Payer: United Healthcare Medicare	$55.62
Rate for Payer: WellCare Medicare	$76.48

MIDAZOLAM HYDROCHLORIDE INJ, PER 1 MG

Facility

$6.18

Service Code	HCPCS J2250
Hospital Charge Code	4400515
Hospital Revenue Code	636
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$4.94
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: Cash Price	$4.64
Rate for Payer: CDPHP Medicare	$2.29
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$0.17
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$4.94
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$4.94
Rate for Payer: EmblemHealth Medicaid	$4.94
Rate for Payer: EmblemHealth Medicare	$2.10
Rate for Payer: EmblemHealth Select Care	$0.17
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 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: Oxford Health Plans Freedom/Liberty/Metro	$0.23
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$0.93
Rate for Payer: United Healthcare Commercial	$0.23
Rate for Payer: United Healthcare Medicare	$2.47
Rate for Payer: WellCare Medicare	$3.40

MIDAZOLAM HYDROCHLORIDE INJ, PER 1 MG

Facility

$6.18

Service Code	HCPCS J2250
Hospital Charge Code	4400517
Hospital Revenue Code	636
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$4.94
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: Cash Price	$4.64
Rate for Payer: CDPHP Medicare	$2.29
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$0.17
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$4.94
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$4.94
Rate for Payer: EmblemHealth Medicaid	$4.94
Rate for Payer: EmblemHealth Medicare	$2.10
Rate for Payer: EmblemHealth Select Care	$0.17
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 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: Oxford Health Plans Freedom/Liberty/Metro	$0.23
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$0.93
Rate for Payer: United Healthcare Commercial	$0.23
Rate for Payer: United Healthcare Medicare	$2.47
Rate for Payer: WellCare Medicare	$3.40

MIDAZOLAM HYDROCHLORIDE INJ, PER 1 MG

Facility

$6.18

Service Code	HCPCS J2250
Hospital Charge Code	4400517
Hospital Revenue Code	636
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$4.02
Rate for Payer: Aetna of NY Commercial	$3.40
Rate for Payer: Cash Price	$4.64
Rate for Payer: Cash Price	$4.64
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$0.17
Rate for Payer: EmblemHealth Select Care	$0.17
Rate for Payer: Galaxy Health Commercial	$4.02
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$3.40
Rate for Payer: WellCare Medicare	$3.40

MIDAZOLAM HYDROCHLORIDE INJ, PER 1 MG

Facility

$6.18

Service Code	HCPCS J2250
Hospital Charge Code	4400515
Hospital Revenue Code	636
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$4.02
Rate for Payer: Aetna of NY Commercial	$3.40
Rate for Payer: Cash Price	$4.64
Rate for Payer: Cash Price	$4.64
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$0.17
Rate for Payer: EmblemHealth Select Care	$0.17
Rate for Payer: Galaxy Health Commercial	$4.02
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$3.40
Rate for Payer: WellCare Medicare	$3.40

MIDODRINE 5 MG TAB, NDC 50268-0565-15

Facility

$12.10

Service Code	NDC 245021211
Hospital Charge Code	4409227
Hospital Revenue Code	250
Min. Negotiated Rate	$6.66
Max. Negotiated Rate	$7.87
Rate for Payer: Cash Price	$9.07
Rate for Payer: Galaxy Health Commercial	$7.87
Rate for Payer: WellCare Medicare	$6.66

MIDODRINE 5 MG TAB, NDC 50268-0565-15

Facility

$12.10

Service Code	NDC 245021211
Hospital Charge Code	4409227
Hospital Revenue Code	250
Min. Negotiated Rate	$1.81
Max. Negotiated Rate	$9.68
Rate for Payer: Aetna of NY Commercial	$8.47
Rate for Payer: Aetna of NY Medicare	$5.57
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$4.84
Rate for Payer: Cash Price	$9.07
Rate for Payer: CDPHP Medicare	$4.48
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$9.68
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$9.68
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$9.68
Rate for Payer: EmblemHealth Medicaid	$9.68
Rate for Payer: EmblemHealth Medicare	$4.11
Rate for Payer: EmblemHealth Select Care	$8.71
Rate for Payer: Fidelis Medicare	$4.84
Rate for Payer: Galaxy Health Commercial	$7.87
Rate for Payer: Hamaspik Choice Medicare	$4.84
Rate for Payer: Humana Medicare	$4.84
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$8.47
Rate for Payer: Local 1199SEIU Medicare	$5.57
Rate for Payer: MVP Health Care of NY Commercial	$9.07
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$6.81
Rate for Payer: MVP Health Care of NY Medicare	$5.08
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$1.81
Rate for Payer: United Healthcare Medicare	$4.84
Rate for Payer: WellCare Medicare	$6.66

Know your out-of-pocket cost for care.

All Charges