Ellenville Regional Hospital

All Charges

Charge

Type

Setting

Price

ALBUTEROL SULFATE ARIN 8 GM

Facility

$79.41

Service Code	NDC 173068224
Hospital Charge Code	4400794
Hospital Revenue Code	250
Min. Negotiated Rate	$11.91
Max. Negotiated Rate	$63.53
Rate for Payer: Aetna of NY Commercial	$55.59
Rate for Payer: Aetna of NY Medicare	$36.53
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$31.76
Rate for Payer: Cash Price	$59.56
Rate for Payer: CDPHP Medicare	$29.38
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$63.53
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$63.53
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$63.53
Rate for Payer: EmblemHealth Medicaid	$63.53
Rate for Payer: EmblemHealth Medicare	$27.00
Rate for Payer: EmblemHealth Select Care	$57.18
Rate for Payer: Fidelis Medicare	$31.76
Rate for Payer: Galaxy Health Commercial	$51.62
Rate for Payer: Hamaspik Choice Medicare	$31.76
Rate for Payer: Humana Medicare	$31.76
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$55.59
Rate for Payer: Local 1199SEIU Medicare	$36.53
Rate for Payer: MVP Health Care of NY Commercial	$59.56
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$44.71
Rate for Payer: MVP Health Care of NY Medicare	$33.35
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$11.91
Rate for Payer: United Healthcare Medicare	$31.76
Rate for Payer: WellCare Medicare	$43.68

ALDOLASE

Facility

$29.00

Service Code	HCPCS 82085
Hospital Charge Code	4300030
Hospital Revenue Code	301
Min. Negotiated Rate	$4.35
Max. Negotiated Rate	$23.20
Rate for Payer: Aetna of NY Commercial	$18.85
Rate for Payer: Aetna of NY Medicare	$13.34
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$11.60
Rate for Payer: Cash Price	$21.75
Rate for Payer: CDPHP Medicare	$10.73
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$17.40
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$23.20
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$23.20
Rate for Payer: EmblemHealth Medicaid	$23.20
Rate for Payer: EmblemHealth Medicare	$9.86
Rate for Payer: EmblemHealth Select Care	$17.40
Rate for Payer: Fidelis Medicare	$11.60
Rate for Payer: Galaxy Health Commercial	$18.85
Rate for Payer: Hamaspik Choice Medicare	$11.60
Rate for Payer: Humana Medicare	$11.60
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$18.85
Rate for Payer: Local 1199SEIU Medicare	$13.34
Rate for Payer: MVP Health Care of NY Commercial	$21.75
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$16.33
Rate for Payer: MVP Health Care of NY Medicare	$12.18
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$21.75
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$4.35
Rate for Payer: United Healthcare Commercial	$21.75
Rate for Payer: United Healthcare Medicare	$11.60
Rate for Payer: WellCare Medicare	$15.95

ALDOLASE

Facility

$29.00

Service Code	HCPCS 82085
Hospital Charge Code	4300030
Hospital Revenue Code	301
Min. Negotiated Rate	$18.85
Max. Negotiated Rate	$18.85
Rate for Payer: Cash Price	$21.75
Rate for Payer: Galaxy Health Commercial	$18.85

ALDOSTERONE & RENIN

Facility

$122.00

Service Code	HCPCS 82088
Hospital Charge Code	4300031
Hospital Revenue Code	301
Min. Negotiated Rate	$18.30
Max. Negotiated Rate	$97.60
Rate for Payer: Aetna of NY Commercial	$79.30
Rate for Payer: Aetna of NY Medicare	$56.12
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$48.80
Rate for Payer: Cash Price	$91.50
Rate for Payer: CDPHP Medicare	$45.14
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$73.20
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$97.60
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$97.60
Rate for Payer: EmblemHealth Medicaid	$97.60
Rate for Payer: EmblemHealth Medicare	$41.48
Rate for Payer: EmblemHealth Select Care	$73.20
Rate for Payer: Fidelis Medicare	$48.80
Rate for Payer: Galaxy Health Commercial	$79.30
Rate for Payer: Hamaspik Choice Medicare	$48.80
Rate for Payer: Humana Medicare	$48.80
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$79.30
Rate for Payer: Local 1199SEIU Medicare	$56.12
Rate for Payer: MVP Health Care of NY Commercial	$91.50
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$68.69
Rate for Payer: MVP Health Care of NY Medicare	$51.24
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$91.50
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$18.30
Rate for Payer: United Healthcare Commercial	$91.50
Rate for Payer: United Healthcare Medicare	$48.80
Rate for Payer: WellCare Medicare	$67.10

ALDOSTERONE & RENIN

Facility

$122.00

Service Code	HCPCS 82088
Hospital Charge Code	4300031
Hospital Revenue Code	301
Min. Negotiated Rate	$79.30
Max. Negotiated Rate	$79.30
Rate for Payer: Cash Price	$91.50
Rate for Payer: Galaxy Health Commercial	$79.30

ALFUZOSIN HCL ER 10 MG TABLET 10 mg, 100 eaches

Facility

$13.00

Service Code	NDC 47335095688
Hospital Charge Code	4401363
Hospital Revenue Code	250
Min. Negotiated Rate	$7.15
Max. Negotiated Rate	$8.45
Rate for Payer: Cash Price	$9.75
Rate for Payer: Galaxy Health Commercial	$8.45
Rate for Payer: WellCare Medicare	$7.15

ALFUZOSIN HCL ER 10 MG TABLET 10 mg, 100 eaches

Facility

$13.00

Service Code	NDC 47335095688
Hospital Charge Code	4401363
Hospital Revenue Code	250
Min. Negotiated Rate	$1.95
Max. Negotiated Rate	$10.40
Rate for Payer: Aetna of NY Commercial	$9.10
Rate for Payer: Aetna of NY Medicare	$5.98
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$5.20
Rate for Payer: Cash Price	$9.75
Rate for Payer: CDPHP Medicare	$4.81
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$10.40
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$10.40
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$10.40
Rate for Payer: EmblemHealth Medicaid	$10.40
Rate for Payer: EmblemHealth Medicare	$4.42
Rate for Payer: EmblemHealth Select Care	$9.36
Rate for Payer: Fidelis Medicare	$5.20
Rate for Payer: Galaxy Health Commercial	$8.45
Rate for Payer: Hamaspik Choice Medicare	$5.20
Rate for Payer: Humana Medicare	$5.20
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$9.10
Rate for Payer: Local 1199SEIU Medicare	$5.98
Rate for Payer: MVP Health Care of NY Commercial	$9.75
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$7.32
Rate for Payer: MVP Health Care of NY Medicare	$5.46
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$1.95
Rate for Payer: United Healthcare Medicare	$5.20
Rate for Payer: WellCare Medicare	$7.15

ALKALINE PHOSPHATASE

Facility

$16.00

Service Code	HCPCS 84075
Hospital Charge Code	4300034
Hospital Revenue Code	301
Min. Negotiated Rate	$10.40
Max. Negotiated Rate	$10.40
Rate for Payer: Cash Price	$12.00
Rate for Payer: Galaxy Health Commercial	$10.40

ALKALINE PHOSPHATASE

Facility

$16.00

Service Code	HCPCS 84075
Hospital Charge Code	4300034
Hospital Revenue Code	301
Min. Negotiated Rate	$2.40
Max. Negotiated Rate	$12.80
Rate for Payer: Aetna of NY Commercial	$10.40
Rate for Payer: Aetna of NY Medicare	$7.36
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$6.40
Rate for Payer: Cash Price	$12.00
Rate for Payer: CDPHP Medicare	$5.92
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$9.60
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$12.80
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$12.80
Rate for Payer: EmblemHealth Medicaid	$12.80
Rate for Payer: EmblemHealth Medicare	$5.44
Rate for Payer: EmblemHealth Select Care	$9.60
Rate for Payer: Fidelis Medicare	$6.40
Rate for Payer: Galaxy Health Commercial	$10.40
Rate for Payer: Hamaspik Choice Medicare	$6.40
Rate for Payer: Humana Medicare	$6.40
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$10.40
Rate for Payer: Local 1199SEIU Medicare	$7.36
Rate for Payer: MVP Health Care of NY Commercial	$12.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$9.01
Rate for Payer: MVP Health Care of NY Medicare	$6.72
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$12.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$2.40
Rate for Payer: United Healthcare Commercial	$12.00
Rate for Payer: United Healthcare Medicare	$6.40
Rate for Payer: WellCare Medicare	$8.80

ALLIANCE_ II INFLATION SYSTEM

Facility

$1,679.93

Hospital Charge Code	4471399
Hospital Revenue Code	270
Min. Negotiated Rate	$251.99
Max. Negotiated Rate	$1,343.94
Rate for Payer: Aetna of NY Commercial	$1,175.95
Rate for Payer: Aetna of NY Medicare	$772.77
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$671.97
Rate for Payer: Cash Price	$1,259.95
Rate for Payer: CDPHP Medicare	$621.57
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$1,343.94
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$1,343.94
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$1,343.94
Rate for Payer: EmblemHealth Medicaid	$1,343.94
Rate for Payer: EmblemHealth Medicare	$571.18
Rate for Payer: EmblemHealth Select Care	$1,209.55
Rate for Payer: Fidelis Medicare	$671.97
Rate for Payer: Galaxy Health Commercial	$1,091.95
Rate for Payer: Hamaspik Choice Medicare	$671.97
Rate for Payer: Humana Medicare	$671.97
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$1,175.95
Rate for Payer: Local 1199SEIU Medicare	$772.77
Rate for Payer: MVP Health Care of NY Commercial	$1,259.95
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$945.80
Rate for Payer: MVP Health Care of NY Medicare	$705.57
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$251.99
Rate for Payer: United Healthcare Medicare	$671.97
Rate for Payer: WellCare Medicare	$923.96

ALLIANCE_ II INFLATION SYSTEM

Facility

$1,679.93

Hospital Charge Code	4471399
Hospital Revenue Code	270
Min. Negotiated Rate	$1,091.95
Max. Negotiated Rate	$1,091.95
Rate for Payer: Cash Price	$1,259.95
Rate for Payer: Galaxy Health Commercial	$1,091.95

ALLOPURINOL 100MG TABS 100 EA

Facility

$6.18

Service Code	NDC 904657161
Hospital Charge Code	4400031
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

ALLOPURINOL 100MG TABS 100 EA

Facility

$6.18

Service Code	NDC 904657161
Hospital Charge Code	4400031
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

ALLOPURINOL 300 MG

Facility

$6.18

Service Code	NDC 51079020601
Hospital Charge Code	4409075
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

ALLOPURINOL 300 MG

Facility

$6.18

Service Code	NDC 51079020601
Hospital Charge Code	4409075
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

ALPHA FETO PROTEIN

Facility

$50.00

Service Code	HCPCS 82105
Hospital Charge Code	4301030
Hospital Revenue Code	300
Min. Negotiated Rate	$32.50
Max. Negotiated Rate	$32.50
Rate for Payer: Cash Price	$37.50
Rate for Payer: Galaxy Health Commercial	$32.50

ALPHA FETO PROTEIN

Facility

$50.00

Service Code	HCPCS 82105
Hospital Charge Code	4301030
Hospital Revenue Code	300
Min. Negotiated Rate	$7.50
Max. Negotiated Rate	$40.00
Rate for Payer: Aetna of NY Commercial	$32.50
Rate for Payer: Aetna of NY Medicare	$23.00
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$20.00
Rate for Payer: Cash Price	$37.50
Rate for Payer: CDPHP Medicare	$18.50
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$30.00
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$40.00
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$40.00
Rate for Payer: EmblemHealth Medicaid	$40.00
Rate for Payer: EmblemHealth Medicare	$17.00
Rate for Payer: EmblemHealth Select Care	$30.00
Rate for Payer: Fidelis Medicare	$20.00
Rate for Payer: Galaxy Health Commercial	$32.50
Rate for Payer: Hamaspik Choice Medicare	$20.00
Rate for Payer: Humana Medicare	$20.00
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$32.50
Rate for Payer: Local 1199SEIU Medicare	$23.00
Rate for Payer: MVP Health Care of NY Commercial	$37.50
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$28.15
Rate for Payer: MVP Health Care of NY Medicare	$21.00
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$37.50
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$7.50
Rate for Payer: United Healthcare Commercial	$37.50
Rate for Payer: United Healthcare Medicare	$20.00
Rate for Payer: WellCare Medicare	$27.50

ALPHAGANP 0.15 OS

Facility

$402.73

Service Code	NDC 61314014405
Hospital Charge Code	4409004
Hospital Revenue Code	250
Min. Negotiated Rate	$60.41
Max. Negotiated Rate	$322.18
Rate for Payer: Aetna of NY Commercial	$281.91
Rate for Payer: Aetna of NY Medicare	$185.26
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$161.09
Rate for Payer: Cash Price	$302.05
Rate for Payer: CDPHP Medicare	$149.01
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$322.18
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$322.18
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$322.18
Rate for Payer: EmblemHealth Medicaid	$322.18
Rate for Payer: EmblemHealth Medicare	$136.93
Rate for Payer: EmblemHealth Select Care	$289.97
Rate for Payer: Fidelis Medicare	$161.09
Rate for Payer: Galaxy Health Commercial	$261.77
Rate for Payer: Hamaspik Choice Medicare	$161.09
Rate for Payer: Humana Medicare	$161.09
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$281.91
Rate for Payer: Local 1199SEIU Medicare	$185.26
Rate for Payer: MVP Health Care of NY Commercial	$302.05
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$226.74
Rate for Payer: MVP Health Care of NY Medicare	$169.15
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$60.41
Rate for Payer: United Healthcare Medicare	$161.09
Rate for Payer: WellCare Medicare	$221.50

ALPHAGANP 0.15 OS

Facility

$402.73

Service Code	NDC 61314014405
Hospital Charge Code	4409004
Hospital Revenue Code	250
Min. Negotiated Rate	$221.50
Max. Negotiated Rate	$261.77
Rate for Payer: Cash Price	$302.05
Rate for Payer: Galaxy Health Commercial	$261.77
Rate for Payer: WellCare Medicare	$221.50

ALPHAGAN P 0.1% DROPS 1 ea, 5 mL

Facility

$580.00

Service Code	NDC 23932105
Hospital Charge Code	4401366
Hospital Revenue Code	250
Min. Negotiated Rate	$87.00
Max. Negotiated Rate	$464.00
Rate for Payer: Aetna of NY Commercial	$406.00
Rate for Payer: Aetna of NY Medicare	$266.80
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$232.00
Rate for Payer: Cash Price	$435.00
Rate for Payer: CDPHP Medicare	$214.60
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$464.00
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$464.00
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$464.00
Rate for Payer: EmblemHealth Medicaid	$464.00
Rate for Payer: EmblemHealth Medicare	$197.20
Rate for Payer: EmblemHealth Select Care	$417.60
Rate for Payer: Fidelis Medicare	$232.00
Rate for Payer: Galaxy Health Commercial	$377.00
Rate for Payer: Hamaspik Choice Medicare	$232.00
Rate for Payer: Humana Medicare	$232.00
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$406.00
Rate for Payer: Local 1199SEIU Medicare	$266.80
Rate for Payer: MVP Health Care of NY Commercial	$435.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$326.54
Rate for Payer: MVP Health Care of NY Medicare	$243.60
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$87.00
Rate for Payer: United Healthcare Medicare	$232.00
Rate for Payer: WellCare Medicare	$319.00

ALPHAGAN P 0.1% DROPS 1 ea, 5 mL

Facility

$580.00

Service Code	NDC 23932105
Hospital Charge Code	4401366
Hospital Revenue Code	250
Min. Negotiated Rate	$319.00
Max. Negotiated Rate	$377.00
Rate for Payer: Cash Price	$435.00
Rate for Payer: Galaxy Health Commercial	$377.00
Rate for Payer: WellCare Medicare	$319.00

ALPRAZOLAM 0.25MG TABS 10X10EA

Facility

$6.18

Service Code	NDC 228202710
Hospital Charge Code	4400032
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

ALPRAZOLAM 0.25MG TABS 10X10EA

Facility

$6.18

Service Code	NDC 228202710
Hospital Charge Code	4400032
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

ALPRAZolam 0.5 MG TABLET 0.5 mg, 100 eaches

Facility

$6.00

Service Code	NDC 904585961
Hospital Charge Code	4401361
Hospital Revenue Code	250
Min. Negotiated Rate	$0.90
Max. Negotiated Rate	$4.80
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) Medicare	$2.40
Rate for Payer: Cash Price	$4.50
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	$2.40
Rate for Payer: Galaxy Health Commercial	$3.90
Rate for Payer: Hamaspik Choice Medicare	$2.40
Rate for Payer: Humana Medicare	$2.40
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	$2.52
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$0.90
Rate for Payer: United Healthcare Medicare	$2.40
Rate for Payer: WellCare Medicare	$3.30

ALPRAZolam 0.5 MG TABLET 0.5 mg, 100 eaches

Facility

$6.00

Service Code	NDC 904585961
Hospital Charge Code	4401361
Hospital Revenue Code	250
Min. Negotiated Rate	$3.30
Max. Negotiated Rate	$3.90
Rate for Payer: Cash Price	$4.50
Rate for Payer: Galaxy Health Commercial	$3.90
Rate for Payer: WellCare Medicare	$3.30

Know your out-of-pocket cost for care.

All Charges