Ellenville Regional Hospital

All Charges

Charge

Type

Setting

Price

AMLODIPINE BESYLATE 10MG TABS 10X10EA

Facility

$7.21

Service Code	NDC 51079045201
Hospital Charge Code	4400040
Hospital Revenue Code	250
Min. Negotiated Rate	$1.08
Max. Negotiated Rate	$5.77
Rate for Payer: Aetna of NY Commercial	$5.05
Rate for Payer: Aetna of NY Medicare	$3.32
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$2.88
Rate for Payer: Cash Price	$5.41
Rate for Payer: CDPHP Medicare	$2.67
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$5.77
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$5.77
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$5.77
Rate for Payer: EmblemHealth Medicaid	$5.77
Rate for Payer: EmblemHealth Medicare	$2.45
Rate for Payer: EmblemHealth Select Care	$5.19
Rate for Payer: Fidelis Medicare	$2.88
Rate for Payer: Galaxy Health Commercial	$4.69
Rate for Payer: Hamaspik Choice Medicare	$2.88
Rate for Payer: Humana Medicare	$2.88
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$5.05
Rate for Payer: Local 1199SEIU Medicare	$3.32
Rate for Payer: MVP Health Care of NY Commercial	$5.41
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$4.06
Rate for Payer: MVP Health Care of NY Medicare	$3.03
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$1.08
Rate for Payer: United Healthcare Medicare	$2.88
Rate for Payer: WellCare Medicare	$3.97

AMLODIPINE BESYLATE 2.5MG TABS 10X10EA

Facility

$6.18

Service Code	NDC 904636961
Hospital Charge Code	4400041
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

AMLODIPINE BESYLATE 2.5MG TABS 10X10EA

Facility

$6.18

Service Code	NDC 904636961
Hospital Charge Code	4400041
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 5MG TABS 10X10EA

Facility

$6.18

Service Code	NDC 904637061
Hospital Charge Code	4400042
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

AMLODIPINE BESYLATE 5MG TABS 10X10EA

Facility

$6.18

Service Code	NDC 904637061
Hospital Charge Code	4400042
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

AMMONIA PLASMA

Facility

$99.00

Service Code	HCPCS 82140
Hospital Charge Code	4300046
Hospital Revenue Code	301
Min. Negotiated Rate	$64.35
Max. Negotiated Rate	$64.35
Rate for Payer: Cash Price	$74.25
Rate for Payer: Galaxy Health Commercial	$64.35

AMMONIA PLASMA

Facility

$99.00

Service Code	HCPCS 82140
Hospital Charge Code	4300046
Hospital Revenue Code	301
Min. Negotiated Rate	$14.85
Max. Negotiated Rate	$79.20
Rate for Payer: Aetna of NY Commercial	$64.35
Rate for Payer: Aetna of NY Medicare	$45.54
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$39.60
Rate for Payer: Cash Price	$74.25
Rate for Payer: CDPHP Medicare	$36.63
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$59.40
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$79.20
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$79.20
Rate for Payer: EmblemHealth Medicaid	$79.20
Rate for Payer: EmblemHealth Medicare	$33.66
Rate for Payer: EmblemHealth Select Care	$59.40
Rate for Payer: Fidelis Medicare	$39.60
Rate for Payer: Galaxy Health Commercial	$64.35
Rate for Payer: Hamaspik Choice Medicare	$39.60
Rate for Payer: Humana Medicare	$39.60
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$64.35
Rate for Payer: Local 1199SEIU Medicare	$45.54
Rate for Payer: MVP Health Care of NY Commercial	$74.25
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$55.74
Rate for Payer: MVP Health Care of NY Medicare	$41.58
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$74.25
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$14.85
Rate for Payer: United Healthcare Commercial	$74.25
Rate for Payer: United Healthcare Medicare	$39.60
Rate for Payer: WellCare Medicare	$54.45

AMMONIUM LACTATE 0.12 CRM 140 GM

Facility

$43.00

Service Code	NDC 45802051377
Hospital Charge Code	4400043
Hospital Revenue Code	250
Min. Negotiated Rate	$23.65
Max. Negotiated Rate	$27.95
Rate for Payer: Cash Price	$32.25
Rate for Payer: Galaxy Health Commercial	$27.95
Rate for Payer: WellCare Medicare	$23.65

AMMONIUM LACTATE 0.12 CRM 140 GM

Facility

$43.00

Service Code	NDC 45802051377
Hospital Charge Code	4400043
Hospital Revenue Code	250
Min. Negotiated Rate	$6.45
Max. Negotiated Rate	$34.40
Rate for Payer: Aetna of NY Commercial	$30.10
Rate for Payer: Aetna of NY Medicare	$19.78
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$17.20
Rate for Payer: Cash Price	$32.25
Rate for Payer: CDPHP Medicare	$15.91
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$34.40
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$34.40
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$34.40
Rate for Payer: EmblemHealth Medicaid	$34.40
Rate for Payer: EmblemHealth Medicare	$14.62
Rate for Payer: EmblemHealth Select Care	$30.96
Rate for Payer: Fidelis Medicare	$17.20
Rate for Payer: Galaxy Health Commercial	$27.95
Rate for Payer: Hamaspik Choice Medicare	$17.20
Rate for Payer: Humana Medicare	$17.20
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$30.10
Rate for Payer: Local 1199SEIU Medicare	$19.78
Rate for Payer: MVP Health Care of NY Commercial	$32.25
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$24.21
Rate for Payer: MVP Health Care of NY Medicare	$18.06
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$6.45
Rate for Payer: United Healthcare Medicare	$17.20
Rate for Payer: WellCare Medicare	$23.65

AMMONIUM LACTATE 0.12 LOTN 225 GM

Facility

$56.39

Service Code	NDC 45802041954
Hospital Charge Code	4400044
Hospital Revenue Code	250
Min. Negotiated Rate	$31.01
Max. Negotiated Rate	$36.65
Rate for Payer: Cash Price	$42.29
Rate for Payer: Galaxy Health Commercial	$36.65
Rate for Payer: WellCare Medicare	$31.01

AMMONIUM LACTATE 0.12 LOTN 225 GM

Facility

$56.39

Service Code	NDC 45802041954
Hospital Charge Code	4400044
Hospital Revenue Code	250
Min. Negotiated Rate	$8.46
Max. Negotiated Rate	$45.11
Rate for Payer: Aetna of NY Commercial	$39.47
Rate for Payer: Aetna of NY Medicare	$25.94
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$22.56
Rate for Payer: Cash Price	$42.29
Rate for Payer: CDPHP Medicare	$20.86
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$45.11
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$45.11
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$45.11
Rate for Payer: EmblemHealth Medicaid	$45.11
Rate for Payer: EmblemHealth Medicare	$19.17
Rate for Payer: EmblemHealth Select Care	$40.60
Rate for Payer: Fidelis Medicare	$22.56
Rate for Payer: Galaxy Health Commercial	$36.65
Rate for Payer: Hamaspik Choice Medicare	$22.56
Rate for Payer: Humana Medicare	$22.56
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$39.47
Rate for Payer: Local 1199SEIU Medicare	$25.94
Rate for Payer: MVP Health Care of NY Commercial	$42.29
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$31.75
Rate for Payer: MVP Health Care of NY Medicare	$23.68
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$8.46
Rate for Payer: United Healthcare Medicare	$22.56
Rate for Payer: WellCare Medicare	$31.01

AMOXICILLIN 250 MG CAP

Facility

$6.18

Service Code	NDC 781202001
Hospital Charge Code	4409014
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

AMOXICILLIN 250 MG CAP

Facility

$6.18

Service Code	NDC 781202001
Hospital Charge Code	4409014
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

AMOXICILLIN 400 MG/5 ML SUSP 400 mg, 100 mL

Facility

$30.00

Service Code	NDC 143988701
Hospital Charge Code	4401546
Hospital Revenue Code	250
Min. Negotiated Rate	$16.50
Max. Negotiated Rate	$19.50
Rate for Payer: Cash Price	$22.50
Rate for Payer: Galaxy Health Commercial	$19.50
Rate for Payer: WellCare Medicare	$16.50

AMOXICILLIN 400 MG/5 ML SUSP 400 mg, 100 mL

Facility

$30.00

Service Code	NDC 143988701
Hospital Charge Code	4401546
Hospital Revenue Code	250
Min. Negotiated Rate	$4.50
Max. Negotiated Rate	$24.00
Rate for Payer: Aetna of NY Commercial	$21.00
Rate for Payer: Aetna of NY Medicare	$13.80
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$12.00
Rate for Payer: Cash Price	$22.50
Rate for Payer: CDPHP Medicare	$11.10
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$24.00
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$24.00
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$24.00
Rate for Payer: EmblemHealth Medicaid	$24.00
Rate for Payer: EmblemHealth Medicare	$10.20
Rate for Payer: EmblemHealth Select Care	$21.60
Rate for Payer: Fidelis Medicare	$12.00
Rate for Payer: Galaxy Health Commercial	$19.50
Rate for Payer: Hamaspik Choice Medicare	$12.00
Rate for Payer: Humana Medicare	$12.00
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$21.00
Rate for Payer: Local 1199SEIU Medicare	$13.80
Rate for Payer: MVP Health Care of NY Commercial	$22.50
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$16.89
Rate for Payer: MVP Health Care of NY Medicare	$12.60
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$4.50
Rate for Payer: United Healthcare Medicare	$12.00
Rate for Payer: WellCare Medicare	$16.50

AMOXICILLIN/POT CLAVULANATE 400-57MG/5ML

Facility

$6.18

Service Code	NDC 66685101200
Hospital Charge Code	4400049
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

AMOXICILLIN/POT CLAVULANATE 400-57MG/5ML

Facility

$6.18

Service Code	NDC 66685101200
Hospital Charge Code	4400049
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

AMOXICILLIN/POT CLAVULANATE 500-125MG TA

Facility

$12.45

Service Code	NDC 66685100202
Hospital Charge Code	4400050
Hospital Revenue Code	250
Min. Negotiated Rate	$6.85
Max. Negotiated Rate	$8.09
Rate for Payer: Cash Price	$9.34
Rate for Payer: Galaxy Health Commercial	$8.09
Rate for Payer: WellCare Medicare	$6.85

AMOXICILLIN/POT CLAVULANATE 500-125MG TA

Facility

$12.45

Service Code	NDC 66685100202
Hospital Charge Code	4400050
Hospital Revenue Code	250
Min. Negotiated Rate	$1.87
Max. Negotiated Rate	$9.96
Rate for Payer: Aetna of NY Commercial	$8.71
Rate for Payer: Aetna of NY Medicare	$5.73
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$4.98
Rate for Payer: Cash Price	$9.34
Rate for Payer: CDPHP Medicare	$4.61
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$9.96
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$9.96
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$9.96
Rate for Payer: EmblemHealth Medicaid	$9.96
Rate for Payer: EmblemHealth Medicare	$4.23
Rate for Payer: EmblemHealth Select Care	$8.96
Rate for Payer: Fidelis Medicare	$4.98
Rate for Payer: Galaxy Health Commercial	$8.09
Rate for Payer: Hamaspik Choice Medicare	$4.98
Rate for Payer: Humana Medicare	$4.98
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$8.71
Rate for Payer: Local 1199SEIU Medicare	$5.73
Rate for Payer: MVP Health Care of NY Commercial	$9.34
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$7.01
Rate for Payer: MVP Health Care of NY Medicare	$5.23
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$1.87
Rate for Payer: United Healthcare Medicare	$4.98
Rate for Payer: WellCare Medicare	$6.85

AMOXICILLIN/POT CLAVULANATE 875-125MG TA

Facility

$15.19

Service Code	NDC 66685100101
Hospital Charge Code	4400051
Hospital Revenue Code	250
Min. Negotiated Rate	$8.35
Max. Negotiated Rate	$9.87
Rate for Payer: Cash Price	$11.39
Rate for Payer: Galaxy Health Commercial	$9.87
Rate for Payer: WellCare Medicare	$8.35

AMOXICILLIN/POT CLAVULANATE 875-125MG TA

Facility

$15.19

Service Code	NDC 66685100101
Hospital Charge Code	4400051
Hospital Revenue Code	250
Min. Negotiated Rate	$2.28
Max. Negotiated Rate	$12.15
Rate for Payer: Aetna of NY Commercial	$10.63
Rate for Payer: Aetna of NY Medicare	$6.99
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$6.08
Rate for Payer: Cash Price	$11.39
Rate for Payer: CDPHP Medicare	$5.62
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$12.15
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$12.15
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$12.15
Rate for Payer: EmblemHealth Medicaid	$12.15
Rate for Payer: EmblemHealth Medicare	$5.16
Rate for Payer: EmblemHealth Select Care	$10.94
Rate for Payer: Fidelis Medicare	$6.08
Rate for Payer: Galaxy Health Commercial	$9.87
Rate for Payer: Hamaspik Choice Medicare	$6.08
Rate for Payer: Humana Medicare	$6.08
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$10.63
Rate for Payer: Local 1199SEIU Medicare	$6.99
Rate for Payer: MVP Health Care of NY Commercial	$11.39
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$8.55
Rate for Payer: MVP Health Care of NY Medicare	$6.38
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$2.28
Rate for Payer: United Healthcare Medicare	$6.08
Rate for Payer: WellCare Medicare	$8.35

AMOXICILLIN TRIHYDRATE 250MG/5ML POSR 80

Facility

$6.18

Service Code	NDC 781604158
Hospital Charge Code	4400045
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

AMOXICILLIN TRIHYDRATE 250MG/5ML POSR 80

Facility

$6.18

Service Code	NDC 781604158
Hospital Charge Code	4400045
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

AMOXICILLIN TRIHYDRATE 400MG/5ML POSR 50

Facility

$6.18

Service Code	NDC 781615752
Hospital Charge Code	4400046
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

AMOXICILLIN TRIHYDRATE 400MG/5ML POSR 50

Facility

$6.18

Service Code	NDC 781615752
Hospital Charge Code	4400046
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

Know your out-of-pocket cost for care.

All Charges