Ellenville Regional Hospital

All Charges

Charge

Type

Setting

Price

ALPRAZOLAM 0.5MG TABS 100 EA

Facility

$6.18

Service Code	NDC 51079078920
Hospital Charge Code	4400033
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 0.5MG TABS 100 EA

Facility

$6.18

Service Code	NDC 51079078920
Hospital Charge Code	4400033
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

ALTEPLASE RECOMBINANT, 1 MG

Facility

$235.50

Service Code	HCPCS J2997
Hospital Charge Code	4400835
Hospital Revenue Code	636
Min. Negotiated Rate	$35.33
Max. Negotiated Rate	$176.62
Rate for Payer: Aetna of NY Medicare	$108.33
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$94.20
Rate for Payer: Cash Price	$176.62
Rate for Payer: Cash Price	$176.62
Rate for Payer: CDPHP Medicare	$87.14
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$95.09
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$88.54
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$73.78
Rate for Payer: EmblemHealth Medicaid	$73.78
Rate for Payer: EmblemHealth Medicare	$80.07
Rate for Payer: EmblemHealth Select Care	$95.09
Rate for Payer: Fidelis Medicare	$94.20
Rate for Payer: Galaxy Health Commercial	$153.07
Rate for Payer: Galaxy Health Workers Comp	$72.30
Rate for Payer: Hamaspik Choice Medicaid	$73.78
Rate for Payer: Hamaspik Choice Medicare	$94.20
Rate for Payer: Humana Medicare	$94.20
Rate for Payer: Local 1199SEIU Medicare	$108.33
Rate for Payer: MVP Health Care of NY Child Health Plus/Family Health Plus/HARP/Medicaid	$77.47
Rate for Payer: MVP Health Care of NY Commercial	$176.62
Rate for Payer: MVP Health Care of NY Essential Plan 1&2	$158.63
Rate for Payer: MVP Health Care of NY Essential Plan 3&4	$158.63
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$132.59
Rate for Payer: MVP Health Care of NY Medicare	$98.91
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$147.10
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$35.33
Rate for Payer: United Healthcare Commercial	$147.10
Rate for Payer: United Healthcare Medicare	$94.20
Rate for Payer: WellCare Child Health Plus/Family Health Plus/Medicaid	$77.47
Rate for Payer: WellCare Medicare	$129.53

ALTEPLASE RECOMBINANT, 1 MG

Facility

$235.50

Service Code	HCPCS J2997
Hospital Charge Code	4400835
Hospital Revenue Code	636
Min. Negotiated Rate	$95.09
Max. Negotiated Rate	$153.07
Rate for Payer: Aetna of NY Commercial	$129.53
Rate for Payer: Cash Price	$176.62
Rate for Payer: Cash Price	$176.62
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$95.09
Rate for Payer: EmblemHealth Select Care	$95.09
Rate for Payer: Galaxy Health Commercial	$153.07
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$129.53
Rate for Payer: WellCare Medicare	$129.53

ALT (SGPT)

Facility

$16.00

Service Code	HCPCS 84460
Hospital Charge Code	4300038
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

ALT (SGPT)

Facility

$16.00

Service Code	HCPCS 84460
Hospital Charge Code	4300038
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

AMANTADINE (GENERIC SYMMETREL) 100 MG CAPSULE

Facility

$6.00

Service Code	NDC 904663061
Hospital Charge Code	4400846
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

AMANTADINE (GENERIC SYMMETREL) 100 MG CAPSULE

Facility

$6.00

Service Code	NDC 904663061
Hospital Charge Code	4400846
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

AMBU SPUR II ADULT, CLOSED R

Facility

$36.05

Hospital Charge Code	4471267
Hospital Revenue Code	270
Min. Negotiated Rate	$5.41
Max. Negotiated Rate	$28.84
Rate for Payer: Aetna of NY Commercial	$25.23
Rate for Payer: Aetna of NY Medicare	$16.58
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$14.42
Rate for Payer: Cash Price	$27.04
Rate for Payer: CDPHP Medicare	$13.34
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$28.84
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$28.84
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$28.84
Rate for Payer: EmblemHealth Medicaid	$28.84
Rate for Payer: EmblemHealth Medicare	$12.26
Rate for Payer: EmblemHealth Select Care	$25.96
Rate for Payer: Fidelis Medicare	$14.42
Rate for Payer: Galaxy Health Commercial	$23.43
Rate for Payer: Hamaspik Choice Medicare	$14.42
Rate for Payer: Humana Medicare	$14.42
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$25.23
Rate for Payer: Local 1199SEIU Medicare	$16.58
Rate for Payer: MVP Health Care of NY Commercial	$27.04
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$20.30
Rate for Payer: MVP Health Care of NY Medicare	$15.14
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$5.41
Rate for Payer: United Healthcare Medicare	$14.42
Rate for Payer: WellCare Medicare	$19.83

AMBU SPUR II ADULT, CLOSED R

Facility

$36.05

Hospital Charge Code	4471267
Hospital Revenue Code	270
Min. Negotiated Rate	$23.43
Max. Negotiated Rate	$23.43
Rate for Payer: Cash Price	$27.04
Rate for Payer: Galaxy Health Commercial	$23.43

AMINOPHYLLINE 250MG INJ

Facility

$38.63

Service Code	HCPCS J0280
Hospital Charge Code	4401277
Hospital Revenue Code	636
Min. Negotiated Rate	$5.79
Max. Negotiated Rate	$30.90
Rate for Payer: Aetna of NY Medicare	$17.77
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$15.45
Rate for Payer: Cash Price	$28.97
Rate for Payer: Cash Price	$28.97
Rate for Payer: CDPHP Medicare	$14.29
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$11.32
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$30.90
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$30.90
Rate for Payer: EmblemHealth Medicaid	$30.90
Rate for Payer: EmblemHealth Medicare	$13.13
Rate for Payer: EmblemHealth Select Care	$11.32
Rate for Payer: Fidelis Medicare	$15.45
Rate for Payer: Galaxy Health Commercial	$25.11
Rate for Payer: Hamaspik Choice Medicare	$15.45
Rate for Payer: Humana Medicare	$15.45
Rate for Payer: Local 1199SEIU Medicare	$17.77
Rate for Payer: MVP Health Care of NY Commercial	$28.97
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$21.75
Rate for Payer: MVP Health Care of NY Medicare	$16.22
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$7.44
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$5.79
Rate for Payer: United Healthcare Commercial	$7.44
Rate for Payer: United Healthcare Medicare	$15.45
Rate for Payer: WellCare Medicare	$21.25

AMINOPHYLLINE 250MG INJ

Facility

$38.63

Service Code	HCPCS J0280
Hospital Charge Code	4401277
Hospital Revenue Code	636
Min. Negotiated Rate	$11.32
Max. Negotiated Rate	$25.11
Rate for Payer: Aetna of NY Commercial	$21.25
Rate for Payer: Cash Price	$28.97
Rate for Payer: Cash Price	$28.97
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$11.32
Rate for Payer: EmblemHealth Select Care	$11.32
Rate for Payer: Galaxy Health Commercial	$25.11
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$21.25
Rate for Payer: WellCare Medicare	$21.25

AMINOSYN 3.5%

Facility

$192.61

Hospital Charge Code	4471542
Hospital Revenue Code	270
Min. Negotiated Rate	$125.20
Max. Negotiated Rate	$125.20
Rate for Payer: Cash Price	$144.46
Rate for Payer: Galaxy Health Commercial	$125.20

AMINOSYN 3.5%

Facility

$192.61

Hospital Charge Code	4471542
Hospital Revenue Code	270
Min. Negotiated Rate	$28.89
Max. Negotiated Rate	$154.09
Rate for Payer: Aetna of NY Commercial	$134.83
Rate for Payer: Aetna of NY Medicare	$88.60
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$77.04
Rate for Payer: Cash Price	$144.46
Rate for Payer: CDPHP Medicare	$71.27
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$154.09
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$154.09
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$154.09
Rate for Payer: EmblemHealth Medicaid	$154.09
Rate for Payer: EmblemHealth Medicare	$65.49
Rate for Payer: EmblemHealth Select Care	$138.68
Rate for Payer: Fidelis Medicare	$77.04
Rate for Payer: Galaxy Health Commercial	$125.20
Rate for Payer: Hamaspik Choice Medicare	$77.04
Rate for Payer: Humana Medicare	$77.04
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$134.83
Rate for Payer: Local 1199SEIU Medicare	$88.60
Rate for Payer: MVP Health Care of NY Commercial	$144.46
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$108.44
Rate for Payer: MVP Health Care of NY Medicare	$80.90
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$28.89
Rate for Payer: United Healthcare Medicare	$77.04
Rate for Payer: WellCare Medicare	$105.94

AMIODARONE 450MG INJ 9ML

Facility

$27.30

Service Code	HCPCS J0282
Hospital Charge Code	4409187
Hospital Revenue Code	636
Min. Negotiated Rate	$0.39
Max. Negotiated Rate	$21.84
Rate for Payer: Aetna of NY Medicare	$12.56
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$10.92
Rate for Payer: Cash Price	$20.48
Rate for Payer: Cash Price	$20.48
Rate for Payer: CDPHP Medicare	$10.10
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$0.39
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$21.84
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$21.84
Rate for Payer: EmblemHealth Medicaid	$21.84
Rate for Payer: EmblemHealth Medicare	$9.28
Rate for Payer: EmblemHealth Select Care	$0.39
Rate for Payer: Fidelis Medicare	$10.92
Rate for Payer: Galaxy Health Commercial	$17.75
Rate for Payer: Hamaspik Choice Medicare	$10.92
Rate for Payer: Humana Medicare	$10.92
Rate for Payer: Local 1199SEIU Medicare	$12.56
Rate for Payer: MVP Health Care of NY Commercial	$20.48
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$15.37
Rate for Payer: MVP Health Care of NY Medicare	$11.47
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$1.35
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$4.09
Rate for Payer: United Healthcare Commercial	$1.35
Rate for Payer: United Healthcare Medicare	$10.92
Rate for Payer: WellCare Medicare	$15.02

AMIODARONE 450MG INJ 9ML

Facility

$27.30

Service Code	HCPCS J0282
Hospital Charge Code	4409187
Hospital Revenue Code	636
Min. Negotiated Rate	$0.39
Max. Negotiated Rate	$17.75
Rate for Payer: Aetna of NY Commercial	$15.02
Rate for Payer: Cash Price	$20.48
Rate for Payer: Cash Price	$20.48
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$0.39
Rate for Payer: EmblemHealth Select Care	$0.39
Rate for Payer: Galaxy Health Commercial	$17.75
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$15.02
Rate for Payer: WellCare Medicare	$15.02

AMIODARONE HCL 200MG TABS 100 EA

Facility

$9.00

Service Code	NDC 245014789
Hospital Charge Code	4400036
Hospital Revenue Code	250
Min. Negotiated Rate	$1.35
Max. Negotiated Rate	$7.20
Rate for Payer: Aetna of NY Commercial	$6.30
Rate for Payer: Aetna of NY Medicare	$4.14
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$3.60
Rate for Payer: Cash Price	$6.75
Rate for Payer: CDPHP Medicare	$3.33
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$7.20
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$7.20
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$7.20
Rate for Payer: EmblemHealth Medicaid	$7.20
Rate for Payer: EmblemHealth Medicare	$3.06
Rate for Payer: EmblemHealth Select Care	$6.48
Rate for Payer: Fidelis Medicare	$3.60
Rate for Payer: Galaxy Health Commercial	$5.85
Rate for Payer: Hamaspik Choice Medicare	$3.60
Rate for Payer: Humana Medicare	$3.60
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$6.30
Rate for Payer: Local 1199SEIU Medicare	$4.14
Rate for Payer: MVP Health Care of NY Commercial	$6.75
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$5.07
Rate for Payer: MVP Health Care of NY Medicare	$3.78
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$1.35
Rate for Payer: United Healthcare Medicare	$3.60
Rate for Payer: WellCare Medicare	$4.95

AMIODARONE HCL 200MG TABS 100 EA

Facility

$9.00

Service Code	NDC 245014789
Hospital Charge Code	4400036
Hospital Revenue Code	250
Min. Negotiated Rate	$4.95
Max. Negotiated Rate	$5.85
Rate for Payer: Cash Price	$6.75
Rate for Payer: Galaxy Health Commercial	$5.85
Rate for Payer: WellCare Medicare	$4.95

AMIODARON HCL INJ 30 MG

Facility

$7.73

Service Code	HCPCS J0282
Hospital Charge Code	4400037
Hospital Revenue Code	636
Min. Negotiated Rate	$0.39
Max. Negotiated Rate	$6.18
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: Cash Price	$5.80
Rate for Payer: CDPHP Medicare	$2.86
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$0.39
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	$0.39
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 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: Oxford Health Plans Freedom/Liberty/Metro	$1.35
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$1.16
Rate for Payer: United Healthcare Commercial	$1.35
Rate for Payer: United Healthcare Medicare	$3.09
Rate for Payer: WellCare Medicare	$4.25

AMIODARON HCL INJ 30 MG

Facility

$7.73

Service Code	HCPCS J0282
Hospital Charge Code	4400037
Hospital Revenue Code	636
Min. Negotiated Rate	$0.39
Max. Negotiated Rate	$5.02
Rate for Payer: Aetna of NY Commercial	$4.25
Rate for Payer: Cash Price	$5.80
Rate for Payer: Cash Price	$5.80
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$0.39
Rate for Payer: EmblemHealth Select Care	$0.39
Rate for Payer: Galaxy Health Commercial	$5.02
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$4.25
Rate for Payer: WellCare Medicare	$4.25

AMITRIPTYLINE HCL 10MG TABS 100 EA

Facility

$6.18

Service Code	NDC 51079013120
Hospital Charge Code	4400038
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

AMITRIPTYLINE HCL 10MG TABS 100 EA

Facility

$6.18

Service Code	NDC 51079013120
Hospital Charge Code	4400038
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

AMITRIPTYLINE HCL 25MG TABS 100 EA

Facility

$6.18

Service Code	NDC 51079010720
Hospital Charge Code	4400039
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

AMITRIPTYLINE HCL 25MG TABS 100 EA

Facility

$6.18

Service Code	NDC 51079010720
Hospital Charge Code	4400039
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

AMLODIPINE BESYLATE 10MG TABS 10X10EA

Facility

$7.21

Service Code	NDC 51079045201
Hospital Charge Code	4400040
Hospital Revenue Code	250
Min. Negotiated Rate	$3.97
Max. Negotiated Rate	$4.69
Rate for Payer: Cash Price	$5.41
Rate for Payer: Galaxy Health Commercial	$4.69
Rate for Payer: WellCare Medicare	$3.97

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