Ellenville Regional Hospital

All Charges

Charge

Type

Setting

Price

OFFICE/OUTPATIENT NEW MODERATE MDM 45 MINUTES

Facility

$366.00

Service Code	HCPCS 99204
Hospital Charge Code	5160003
Hospital Revenue Code	516
Min. Negotiated Rate	$237.90
Max. Negotiated Rate	$237.90
Rate for Payer: Cash Price	$274.50
Rate for Payer: Galaxy Health Commercial	$237.90

OFFICE/OUTPATIENT NEW MODERATE MDM 45 MINUTES

Facility

$366.00

Service Code	HCPCS 99204
Hospital Charge Code	4850003
Hospital Revenue Code	761
Min. Negotiated Rate	$237.90
Max. Negotiated Rate	$237.90
Rate for Payer: Cash Price	$274.50
Rate for Payer: Galaxy Health Commercial	$237.90

OFFICE/OUTPATIENT NEW MODERATE MDM 45 MINUTES

Facility

$366.00

Service Code	HCPCS 99204
Hospital Charge Code	4850003
Hospital Revenue Code	761
Min. Negotiated Rate	$54.90
Max. Negotiated Rate	$292.80
Rate for Payer: Aetna of NY Commercial	$256.20
Rate for Payer: Aetna of NY Medicare	$168.36
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$146.40
Rate for Payer: Cash Price	$274.50
Rate for Payer: CDPHP Medicare	$135.42
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$292.80
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$292.80
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$292.80
Rate for Payer: EmblemHealth Medicaid	$292.80
Rate for Payer: EmblemHealth Medicare	$124.44
Rate for Payer: EmblemHealth Select Care	$263.52
Rate for Payer: Fidelis Medicare	$146.40
Rate for Payer: Galaxy Health Commercial	$237.90
Rate for Payer: Hamaspik Choice Medicare	$146.40
Rate for Payer: Humana Medicare	$146.40
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$256.20
Rate for Payer: Local 1199SEIU Medicare	$168.36
Rate for Payer: MVP Health Care of NY Commercial	$274.50
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$206.06
Rate for Payer: MVP Health Care of NY Medicare	$153.72
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$54.90
Rate for Payer: United Healthcare Medicare	$146.40
Rate for Payer: WellCare Medicare	$201.30

OFFICE/OUTPATIENT NEW MODERATE MDM 45 MINUTES

Facility

$366.00

Service Code	HCPCS 99204
Hospital Charge Code	5160003
Hospital Revenue Code	516
Min. Negotiated Rate	$54.90
Max. Negotiated Rate	$292.80
Rate for Payer: Aetna of NY Commercial	$256.20
Rate for Payer: Aetna of NY Medicare	$168.36
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$146.40
Rate for Payer: Cash Price	$274.50
Rate for Payer: Cash Price	$274.50
Rate for Payer: CDPHP Medicare	$135.42
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$292.80
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$292.80
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$292.80
Rate for Payer: EmblemHealth Medicaid	$292.80
Rate for Payer: EmblemHealth Medicare	$124.44
Rate for Payer: EmblemHealth Select Care	$263.52
Rate for Payer: Fidelis Medicare	$146.40
Rate for Payer: Galaxy Health Commercial	$237.90
Rate for Payer: Hamaspik Choice Medicare	$146.40
Rate for Payer: Humana Medicare	$146.40
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$256.20
Rate for Payer: Local 1199SEIU Medicare	$168.36
Rate for Payer: MVP Health Care of NY Commercial	$274.50
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$206.06
Rate for Payer: MVP Health Care of NY Medicare	$153.72
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$161.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$54.90
Rate for Payer: United Healthcare Commercial	$161.00
Rate for Payer: United Healthcare Medicare	$146.40
Rate for Payer: WellCare Medicare	$201.30

OFFICE/OUTPATIENT NEW SF MDM 15 MINUTES

Facility

$181.00

Service Code	HCPCS 99202
Hospital Charge Code	4850001
Hospital Revenue Code	761
Min. Negotiated Rate	$27.15
Max. Negotiated Rate	$144.80
Rate for Payer: Aetna of NY Commercial	$126.70
Rate for Payer: Aetna of NY Medicare	$83.26
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$72.40
Rate for Payer: Cash Price	$135.75
Rate for Payer: CDPHP Medicare	$66.97
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$144.80
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$144.80
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$144.80
Rate for Payer: EmblemHealth Medicaid	$144.80
Rate for Payer: EmblemHealth Medicare	$61.54
Rate for Payer: EmblemHealth Select Care	$130.32
Rate for Payer: Fidelis Medicare	$72.40
Rate for Payer: Galaxy Health Commercial	$117.65
Rate for Payer: Hamaspik Choice Medicare	$72.40
Rate for Payer: Humana Medicare	$72.40
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$126.70
Rate for Payer: Local 1199SEIU Medicare	$83.26
Rate for Payer: MVP Health Care of NY Commercial	$135.75
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$101.90
Rate for Payer: MVP Health Care of NY Medicare	$76.02
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$27.15
Rate for Payer: United Healthcare Medicare	$72.40
Rate for Payer: WellCare Medicare	$99.55

OFFICE/OUTPATIENT NEW SF MDM 15 MINUTES

Facility

$181.00

Service Code	HCPCS 99202
Hospital Charge Code	4850001
Hospital Revenue Code	761
Min. Negotiated Rate	$117.65
Max. Negotiated Rate	$117.65
Rate for Payer: Cash Price	$135.75
Rate for Payer: Galaxy Health Commercial	$117.65

OFFICE/OUTPATIENT NEW SF MDM 15 MINUTES

Facility

$181.00

Service Code	HCPCS 99202
Hospital Charge Code	5160001
Hospital Revenue Code	516
Min. Negotiated Rate	$27.15
Max. Negotiated Rate	$161.00
Rate for Payer: Aetna of NY Commercial	$126.70
Rate for Payer: Aetna of NY Medicare	$83.26
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$72.40
Rate for Payer: Cash Price	$135.75
Rate for Payer: Cash Price	$135.75
Rate for Payer: CDPHP Medicare	$66.97
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$144.80
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$144.80
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$144.80
Rate for Payer: EmblemHealth Medicaid	$144.80
Rate for Payer: EmblemHealth Medicare	$61.54
Rate for Payer: EmblemHealth Select Care	$130.32
Rate for Payer: Fidelis Medicare	$72.40
Rate for Payer: Galaxy Health Commercial	$117.65
Rate for Payer: Hamaspik Choice Medicare	$72.40
Rate for Payer: Humana Medicare	$72.40
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$126.70
Rate for Payer: Local 1199SEIU Medicare	$83.26
Rate for Payer: MVP Health Care of NY Commercial	$135.75
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$101.90
Rate for Payer: MVP Health Care of NY Medicare	$76.02
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$161.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$27.15
Rate for Payer: United Healthcare Commercial	$161.00
Rate for Payer: United Healthcare Medicare	$72.40
Rate for Payer: WellCare Medicare	$99.55

OFFICE/OUTPATIENT NEW SF MDM 15 MINUTES

Facility

$181.00

Service Code	HCPCS 99202
Hospital Charge Code	5160001
Hospital Revenue Code	516
Min. Negotiated Rate	$117.65
Max. Negotiated Rate	$117.65
Rate for Payer: Cash Price	$135.75
Rate for Payer: Galaxy Health Commercial	$117.65

OFLOXACIN 0.003 DROP 5 ML

Facility

$69.53

Service Code	NDC 64980051505
Hospital Charge Code	4400584
Hospital Revenue Code	250
Min. Negotiated Rate	$38.24
Max. Negotiated Rate	$45.19
Rate for Payer: Cash Price	$52.15
Rate for Payer: Galaxy Health Commercial	$45.19
Rate for Payer: WellCare Medicare	$38.24

OFLOXACIN 0.003 DROP 5 ML

Facility

$69.53

Service Code	NDC 64980051505
Hospital Charge Code	4400584
Hospital Revenue Code	250
Min. Negotiated Rate	$10.43
Max. Negotiated Rate	$55.62
Rate for Payer: Aetna of NY Commercial	$48.67
Rate for Payer: Aetna of NY Medicare	$31.98
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$27.81
Rate for Payer: Cash Price	$52.15
Rate for Payer: CDPHP Medicare	$25.73
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$55.62
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$55.62
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$55.62
Rate for Payer: EmblemHealth Medicaid	$55.62
Rate for Payer: EmblemHealth Medicare	$23.64
Rate for Payer: EmblemHealth Select Care	$50.06
Rate for Payer: Fidelis Medicare	$27.81
Rate for Payer: Galaxy Health Commercial	$45.19
Rate for Payer: Hamaspik Choice Medicare	$27.81
Rate for Payer: Humana Medicare	$27.81
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$48.67
Rate for Payer: Local 1199SEIU Medicare	$31.98
Rate for Payer: MVP Health Care of NY Commercial	$52.15
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$39.15
Rate for Payer: MVP Health Care of NY Medicare	$29.20
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$10.43
Rate for Payer: United Healthcare Medicare	$27.81
Rate for Payer: WellCare Medicare	$38.24

OFLOXACIN Otic Sol

Facility

$229.43

Service Code	NDC 60505036301
Hospital Charge Code	4409005
Hospital Revenue Code	250
Min. Negotiated Rate	$126.19
Max. Negotiated Rate	$149.13
Rate for Payer: Cash Price	$172.07
Rate for Payer: Galaxy Health Commercial	$149.13
Rate for Payer: WellCare Medicare	$126.19

OFLOXACIN Otic Sol

Facility

$229.43

Service Code	NDC 60505036301
Hospital Charge Code	4409005
Hospital Revenue Code	250
Min. Negotiated Rate	$34.41
Max. Negotiated Rate	$183.54
Rate for Payer: Aetna of NY Commercial	$160.60
Rate for Payer: Aetna of NY Medicare	$105.54
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$91.77
Rate for Payer: Cash Price	$172.07
Rate for Payer: CDPHP Medicare	$84.89
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$183.54
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$183.54
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$183.54
Rate for Payer: EmblemHealth Medicaid	$183.54
Rate for Payer: EmblemHealth Medicare	$78.01
Rate for Payer: EmblemHealth Select Care	$165.19
Rate for Payer: Fidelis Medicare	$91.77
Rate for Payer: Galaxy Health Commercial	$149.13
Rate for Payer: Hamaspik Choice Medicare	$91.77
Rate for Payer: Humana Medicare	$91.77
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$160.60
Rate for Payer: Local 1199SEIU Medicare	$105.54
Rate for Payer: MVP Health Care of NY Commercial	$172.07
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$129.17
Rate for Payer: MVP Health Care of NY Medicare	$96.36
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$34.41
Rate for Payer: United Healthcare Medicare	$91.77
Rate for Payer: WellCare Medicare	$126.19

OIL EMULSION 3IN X 3IN

Facility

$5.15

Hospital Charge Code	4471626
Hospital Revenue Code	270
Min. Negotiated Rate	$3.35
Max. Negotiated Rate	$3.35
Rate for Payer: Cash Price	$3.86
Rate for Payer: Galaxy Health Commercial	$3.35

OIL EMULSION 3IN X 3IN

Facility

$5.15

Hospital Charge Code	4471626
Hospital Revenue Code	270
Min. Negotiated Rate	$0.77
Max. Negotiated Rate	$4.12
Rate for Payer: Aetna of NY Commercial	$3.60
Rate for Payer: Aetna of NY Medicare	$2.37
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$2.06
Rate for Payer: Cash Price	$3.86
Rate for Payer: CDPHP Medicare	$1.91
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$4.12
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$4.12
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$4.12
Rate for Payer: EmblemHealth Medicaid	$4.12
Rate for Payer: EmblemHealth Medicare	$1.75
Rate for Payer: EmblemHealth Select Care	$3.71
Rate for Payer: Fidelis Medicare	$2.06
Rate for Payer: Galaxy Health Commercial	$3.35
Rate for Payer: Hamaspik Choice Medicare	$2.06
Rate for Payer: Humana Medicare	$2.06
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$3.60
Rate for Payer: Local 1199SEIU Medicare	$2.37
Rate for Payer: MVP Health Care of NY Commercial	$3.86
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$2.90
Rate for Payer: MVP Health Care of NY Medicare	$2.16
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$0.77
Rate for Payer: United Healthcare Medicare	$2.06
Rate for Payer: WellCare Medicare	$2.83

OLANZAPINE 5MG TABS 30 EA

Facility

$40.94

Service Code	NDC 904637761
Hospital Charge Code	4400829
Hospital Revenue Code	250
Min. Negotiated Rate	$6.14
Max. Negotiated Rate	$32.75
Rate for Payer: Aetna of NY Commercial	$28.66
Rate for Payer: Aetna of NY Medicare	$18.83
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$16.38
Rate for Payer: Cash Price	$30.70
Rate for Payer: CDPHP Medicare	$15.15
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$32.75
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$32.75
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$32.75
Rate for Payer: EmblemHealth Medicaid	$32.75
Rate for Payer: EmblemHealth Medicare	$13.92
Rate for Payer: EmblemHealth Select Care	$29.48
Rate for Payer: Fidelis Medicare	$16.38
Rate for Payer: Galaxy Health Commercial	$26.61
Rate for Payer: Hamaspik Choice Medicare	$16.38
Rate for Payer: Humana Medicare	$16.38
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$28.66
Rate for Payer: Local 1199SEIU Medicare	$18.83
Rate for Payer: MVP Health Care of NY Commercial	$30.70
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$23.05
Rate for Payer: MVP Health Care of NY Medicare	$17.19
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$6.14
Rate for Payer: United Healthcare Medicare	$16.38
Rate for Payer: WellCare Medicare	$22.52

OLANZAPINE 5MG TABS 30 EA

Facility

$40.94

Service Code	NDC 904637761
Hospital Charge Code	4400829
Hospital Revenue Code	250
Min. Negotiated Rate	$22.52
Max. Negotiated Rate	$26.61
Rate for Payer: Cash Price	$30.70
Rate for Payer: Galaxy Health Commercial	$26.61
Rate for Payer: WellCare Medicare	$22.52

OLIVE STABILIZER

Facility

$1,381.23

Hospital Charge Code	4471666
Hospital Revenue Code	278
Min. Negotiated Rate	$207.18
Max. Negotiated Rate	$1,104.98
Rate for Payer: Aetna of NY Commercial	$966.86
Rate for Payer: Aetna of NY Medicare	$635.37
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$552.49
Rate for Payer: Cash Price	$1,035.92
Rate for Payer: CDPHP Medicare	$511.06
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$690.62
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$1,104.98
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$1,104.98
Rate for Payer: EmblemHealth Medicaid	$1,104.98
Rate for Payer: EmblemHealth Medicare	$469.62
Rate for Payer: EmblemHealth Select Care	$690.62
Rate for Payer: Fidelis Medicare	$552.49
Rate for Payer: Galaxy Health Commercial	$897.80
Rate for Payer: Hamaspik Choice Medicare	$552.49
Rate for Payer: Humana Medicare	$552.49
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$966.86
Rate for Payer: Local 1199SEIU Medicare	$635.37
Rate for Payer: MVP Health Care of NY Commercial	$897.80
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$897.80
Rate for Payer: MVP Health Care of NY Medicare	$580.12
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$207.18
Rate for Payer: United Healthcare Medicare	$552.49
Rate for Payer: WellCare Medicare	$759.68

OLIVE STABILIZER

Facility

$1,381.23

Hospital Charge Code	4471666
Hospital Revenue Code	278
Min. Negotiated Rate	$621.55
Max. Negotiated Rate	$966.86
Rate for Payer: Aetna of NY Commercial	$966.86
Rate for Payer: Cash Price	$1,035.92
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$690.62
Rate for Payer: EmblemHealth Select Care	$690.62
Rate for Payer: Galaxy Health Commercial	$897.80
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$966.86
Rate for Payer: Multiplan Commercial	$621.55
Rate for Payer: MVP Health Care of NY Commercial	$897.80
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$897.80
Rate for Payer: WellCare Medicare	$759.68

OLOPATADINE HCL 0.001 DROP 5 ML

Facility

$880.65

Service Code	NDC 65027105
Hospital Charge Code	4400610
Hospital Revenue Code	250
Min. Negotiated Rate	$132.10
Max. Negotiated Rate	$704.52
Rate for Payer: Aetna of NY Commercial	$616.46
Rate for Payer: Aetna of NY Medicare	$405.10
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$352.26
Rate for Payer: Cash Price	$660.49
Rate for Payer: CDPHP Medicare	$325.84
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$704.52
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$704.52
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$704.52
Rate for Payer: EmblemHealth Medicaid	$704.52
Rate for Payer: EmblemHealth Medicare	$299.42
Rate for Payer: EmblemHealth Select Care	$634.07
Rate for Payer: Fidelis Medicare	$352.26
Rate for Payer: Galaxy Health Commercial	$572.42
Rate for Payer: Hamaspik Choice Medicare	$352.26
Rate for Payer: Humana Medicare	$352.26
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$616.46
Rate for Payer: Local 1199SEIU Medicare	$405.10
Rate for Payer: MVP Health Care of NY Commercial	$660.49
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$495.81
Rate for Payer: MVP Health Care of NY Medicare	$369.87
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$132.10
Rate for Payer: United Healthcare Medicare	$352.26
Rate for Payer: WellCare Medicare	$484.36

OLOPATADINE HCL 0.001 DROP 5 ML

Facility

$880.65

Service Code	NDC 65027105
Hospital Charge Code	4400610
Hospital Revenue Code	250
Min. Negotiated Rate	$484.36
Max. Negotiated Rate	$572.42
Rate for Payer: Cash Price	$660.49
Rate for Payer: Galaxy Health Commercial	$572.42
Rate for Payer: WellCare Medicare	$484.36

OMEGA-3-ACID ETHYL ESTERS 1GM GCAP 120 E

Facility

$8.79

Service Code	NDC 60505317007
Hospital Charge Code	4400470
Hospital Revenue Code	250
Min. Negotiated Rate	$1.32
Max. Negotiated Rate	$7.03
Rate for Payer: Aetna of NY Commercial	$6.15
Rate for Payer: Aetna of NY Medicare	$4.04
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$3.52
Rate for Payer: Cash Price	$6.59
Rate for Payer: CDPHP Medicare	$3.25
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$7.03
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$7.03
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$7.03
Rate for Payer: EmblemHealth Medicaid	$7.03
Rate for Payer: EmblemHealth Medicare	$2.99
Rate for Payer: EmblemHealth Select Care	$6.33
Rate for Payer: Fidelis Medicare	$3.52
Rate for Payer: Galaxy Health Commercial	$5.71
Rate for Payer: Hamaspik Choice Medicare	$3.52
Rate for Payer: Humana Medicare	$3.52
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$6.15
Rate for Payer: Local 1199SEIU Medicare	$4.04
Rate for Payer: MVP Health Care of NY Commercial	$6.59
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$4.95
Rate for Payer: MVP Health Care of NY Medicare	$3.69
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$1.32
Rate for Payer: United Healthcare Medicare	$3.52
Rate for Payer: WellCare Medicare	$4.83

OMEGA-3-ACID ETHYL ESTERS 1GM GCAP 120 E

Facility

$8.79

Service Code	NDC 60505317007
Hospital Charge Code	4400470
Hospital Revenue Code	250
Min. Negotiated Rate	$4.83
Max. Negotiated Rate	$5.71
Rate for Payer: Cash Price	$6.59
Rate for Payer: Galaxy Health Commercial	$5.71
Rate for Payer: WellCare Medicare	$4.83

OMNIPAQUE / LOCM 200-299MG/ML IODINE,1ML

Facility

$1.03

Service Code	HCPCS Q9966
Hospital Charge Code	4211264
Hospital Revenue Code	636
Min. Negotiated Rate	$0.43
Max. Negotiated Rate	$0.67
Rate for Payer: Aetna of NY Commercial	$0.57
Rate for Payer: Cash Price	$0.77
Rate for Payer: Cash Price	$0.77
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$0.43
Rate for Payer: EmblemHealth Select Care	$0.43
Rate for Payer: Galaxy Health Commercial	$0.67
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$0.57
Rate for Payer: WellCare Medicare	$0.57

OMNIPAQUE / LOCM 200-299MG/ML IODINE,1ML

Facility

$1.03

Service Code	HCPCS Q9966
Hospital Charge Code	4211264
Hospital Revenue Code	636
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.82
Rate for Payer: Aetna of NY Medicare	$0.47
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$0.41
Rate for Payer: Cash Price	$0.77
Rate for Payer: Cash Price	$0.77
Rate for Payer: CDPHP Medicare	$0.38
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$0.43
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$0.82
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$0.82
Rate for Payer: EmblemHealth Medicaid	$0.82
Rate for Payer: EmblemHealth Medicare	$0.35
Rate for Payer: EmblemHealth Select Care	$0.43
Rate for Payer: Fidelis Medicare	$0.41
Rate for Payer: Galaxy Health Commercial	$0.67
Rate for Payer: Hamaspik Choice Medicare	$0.41
Rate for Payer: Humana Medicare	$0.41
Rate for Payer: Local 1199SEIU Medicare	$0.47
Rate for Payer: MVP Health Care of NY Commercial	$0.77
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$0.58
Rate for Payer: MVP Health Care of NY Medicare	$0.43
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$0.61
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$0.15
Rate for Payer: United Healthcare Commercial	$0.61
Rate for Payer: United Healthcare Medicare	$0.41
Rate for Payer: WellCare Medicare	$0.57

ONDANSETRON 4 MG TABLET

Facility

$76.48

Service Code	NDC 904655161
Hospital Charge Code	4401246
Hospital Revenue Code	250
Min. Negotiated Rate	$11.47
Max. Negotiated Rate	$61.18
Rate for Payer: Aetna of NY Commercial	$53.54
Rate for Payer: Aetna of NY Medicare	$35.18
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$30.59
Rate for Payer: Cash Price	$57.36
Rate for Payer: CDPHP Medicare	$28.30
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$61.18
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$61.18
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$61.18
Rate for Payer: EmblemHealth Medicaid	$61.18
Rate for Payer: EmblemHealth Medicare	$26.00
Rate for Payer: EmblemHealth Select Care	$55.07
Rate for Payer: Fidelis Medicare	$30.59
Rate for Payer: Galaxy Health Commercial	$49.71
Rate for Payer: Hamaspik Choice Medicare	$30.59
Rate for Payer: Humana Medicare	$30.59
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$53.54
Rate for Payer: Local 1199SEIU Medicare	$35.18
Rate for Payer: MVP Health Care of NY Commercial	$57.36
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$43.06
Rate for Payer: MVP Health Care of NY Medicare	$32.12
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$11.47
Rate for Payer: United Healthcare Medicare	$30.59
Rate for Payer: WellCare Medicare	$42.06

Know your out-of-pocket cost for care.

All Charges