Ellenville Regional Hospital

All Charges

Charge

Type

Setting

Price

SMZ-TMP SUSP

Facility

$6.95

Service Code	NDC 65862049647
Hospital Charge Code	4408978
Hospital Revenue Code	250
Min. Negotiated Rate	$2.36
Max. Negotiated Rate	$5.59
Rate for Payer: Aetna of NY Commercial	$4.86
Rate for Payer: Aetna of NY Medicare	$3.20
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group	$5.21
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO	$5.21
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$2.57
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp	$3.48
Rate for Payer: Cash Price	$5.21
Rate for Payer: CDPHP Commercial	$5.59
Rate for Payer: CDPHP Medicare	$2.57
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$5.56
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$5.56
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$5.56
Rate for Payer: EmblemHealth Medicaid	$5.56
Rate for Payer: EmblemHealth Medicare	$2.36
Rate for Payer: EmblemHealth Select Care	$5.00
Rate for Payer: Fidelis Medicare	$2.65
Rate for Payer: Galaxy Health Commercial	$4.52
Rate for Payer: Hamaspik Choice Medicare	$2.57
Rate for Payer: Humana Medicare	$2.57
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$4.86
Rate for Payer: Local 1199SEIU Medicare	$3.20
Rate for Payer: MVP Health Care of NY Commercial	$5.21
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$3.91
Rate for Payer: MVP Health Care of NY Medicare	$2.70
Rate for Payer: United Healthcare Medicare	$2.57
Rate for Payer: WellCare Medicare	$3.82

SMZ-TMP SUSP

Facility

$6.95

Service Code	NDC 65862049647
Hospital Charge Code	4408978
Hospital Revenue Code	250
Min. Negotiated Rate	$3.82
Max. Negotiated Rate	$4.52
Rate for Payer: Cash Price	$5.21
Rate for Payer: Galaxy Health Commercial	$4.52
Rate for Payer: WellCare Medicare	$3.82

SODIUM BICARBONATE 0.5MEQ/ML SDV 25X5ML

Facility

$6.18

Service Code	NDC 63323002605
Hospital Charge Code	4400705
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

SODIUM BICARBONATE 0.5MEQ/ML SDV 25X5ML

Facility

$6.18

Service Code	NDC 63323002605
Hospital Charge Code	4400705
Hospital Revenue Code	250
Min. Negotiated Rate	$2.10
Max. Negotiated Rate	$4.97
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) Blue Access/Small Group	$4.64
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO	$4.64
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$2.29
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp	$3.09
Rate for Payer: Cash Price	$4.64
Rate for Payer: CDPHP Commercial	$4.97
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	$2.36
Rate for Payer: Galaxy Health Commercial	$4.02
Rate for Payer: Hamaspik Choice Medicare	$2.29
Rate for Payer: Humana Medicare	$2.29
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	$4.64
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$3.48
Rate for Payer: MVP Health Care of NY Medicare	$2.40
Rate for Payer: United Healthcare Medicare	$2.29
Rate for Payer: WellCare Medicare	$3.40

SODIUM BICARBONATE 1MEQ/ML LSSY 10X50ML

Facility

$39.14

Service Code	NDC 00409663734
Hospital Charge Code	4400706
Hospital Revenue Code	250
Min. Negotiated Rate	$13.31
Max. Negotiated Rate	$31.51
Rate for Payer: Aetna of NY Commercial	$27.40
Rate for Payer: Aetna of NY Medicare	$18.00
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group	$29.36
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO	$29.36
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$14.48
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp	$19.57
Rate for Payer: Cash Price	$29.36
Rate for Payer: CDPHP Commercial	$31.51
Rate for Payer: CDPHP Medicare	$14.48
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$31.31
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$31.31
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$31.31
Rate for Payer: EmblemHealth Medicaid	$31.31
Rate for Payer: EmblemHealth Medicare	$13.31
Rate for Payer: EmblemHealth Select Care	$28.18
Rate for Payer: Fidelis Medicare	$14.92
Rate for Payer: Galaxy Health Commercial	$25.44
Rate for Payer: Hamaspik Choice Medicare	$14.48
Rate for Payer: Humana Medicare	$14.48
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$27.40
Rate for Payer: Local 1199SEIU Medicare	$18.00
Rate for Payer: MVP Health Care of NY Commercial	$29.36
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$22.04
Rate for Payer: MVP Health Care of NY Medicare	$15.21
Rate for Payer: United Healthcare Medicare	$14.48
Rate for Payer: WellCare Medicare	$21.53

SODIUM BICARBONATE 1MEQ/ML LSSY 10X50ML

Facility

$39.14

Service Code	NDC 00409663734
Hospital Charge Code	4400706
Hospital Revenue Code	250
Min. Negotiated Rate	$21.53
Max. Negotiated Rate	$25.44
Rate for Payer: Cash Price	$29.36
Rate for Payer: Galaxy Health Commercial	$25.44
Rate for Payer: WellCare Medicare	$21.53

SODIUM BICARBONATE 325MG TABS 100 EA

Facility

$6.18

Service Code	NDC 00223172001
Hospital Charge Code	4400707
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

SODIUM BICARBONATE 325MG TABS 100 EA

Facility

$6.18

Service Code	NDC 00223172001
Hospital Charge Code	4400707
Hospital Revenue Code	250
Min. Negotiated Rate	$2.10
Max. Negotiated Rate	$4.97
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) Blue Access/Small Group	$4.64
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO	$4.64
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$2.29
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp	$3.09
Rate for Payer: Cash Price	$4.64
Rate for Payer: CDPHP Commercial	$4.97
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	$2.36
Rate for Payer: Galaxy Health Commercial	$4.02
Rate for Payer: Hamaspik Choice Medicare	$2.29
Rate for Payer: Humana Medicare	$2.29
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	$4.64
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$3.48
Rate for Payer: MVP Health Care of NY Medicare	$2.40
Rate for Payer: United Healthcare Medicare	$2.29
Rate for Payer: WellCare Medicare	$3.40

SODIUM BORATE/SOD CL/BORIC AC SOLN 120

Facility

$9.50

Service Code	NDC 00536122497
Hospital Charge Code	4400283
Hospital Revenue Code	250
Min. Negotiated Rate	$5.22
Max. Negotiated Rate	$6.18
Rate for Payer: Cash Price	$7.13
Rate for Payer: Galaxy Health Commercial	$6.18
Rate for Payer: WellCare Medicare	$5.22

SODIUM BORATE/SOD CL/BORIC AC SOLN 120

Facility

$9.50

Service Code	NDC 00536122497
Hospital Charge Code	4400283
Hospital Revenue Code	250
Min. Negotiated Rate	$3.23
Max. Negotiated Rate	$7.65
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) Blue Access/Small Group	$7.12
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO	$7.12
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$3.52
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp	$4.75
Rate for Payer: Cash Price	$7.13
Rate for Payer: CDPHP Commercial	$7.65
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	$3.62
Rate for Payer: Galaxy Health Commercial	$6.18
Rate for Payer: Hamaspik Choice Medicare	$3.52
Rate for Payer: Humana Medicare	$3.52
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	$3.69
Rate for Payer: United Healthcare Medicare	$3.52
Rate for Payer: WellCare Medicare	$5.22

SODIUM CHLORIDE 0.65% 0.0065 SPIN 45 ML

Facility

$7.21

Service Code	NDC 00536250676
Hospital Charge Code	4400687
Hospital Revenue Code	250
Min. Negotiated Rate	$2.45
Max. Negotiated Rate	$5.80
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) Blue Access/Small Group	$5.41
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO	$5.41
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$2.67
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp	$3.60
Rate for Payer: Cash Price	$5.41
Rate for Payer: CDPHP Commercial	$5.80
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	$2.75
Rate for Payer: Galaxy Health Commercial	$4.69
Rate for Payer: Hamaspik Choice Medicare	$2.67
Rate for Payer: Humana Medicare	$2.67
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	$2.80
Rate for Payer: United Healthcare Medicare	$2.67
Rate for Payer: WellCare Medicare	$3.97

SODIUM CHLORIDE 0.65% 0.0065 SPIN 45 ML

Facility

$7.21

Service Code	NDC 00536250676
Hospital Charge Code	4400687
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

SODIUM CHLORIDE 0.9% 0.009 IVSL 80X100ML

Facility

$18.54

Service Code	NDC 00338055318
Hospital Charge Code	4450014
Hospital Revenue Code	250
Min. Negotiated Rate	$10.20
Max. Negotiated Rate	$12.05
Rate for Payer: Cash Price	$13.91
Rate for Payer: Galaxy Health Commercial	$12.05
Rate for Payer: WellCare Medicare	$10.20

SODIUM CHLORIDE 0.9% 0.009 IVSL 80X100ML

Facility

$18.54

Service Code	NDC 00338055318
Hospital Charge Code	4450014
Hospital Revenue Code	250
Min. Negotiated Rate	$6.30
Max. Negotiated Rate	$14.92
Rate for Payer: Aetna of NY Commercial	$12.98
Rate for Payer: Aetna of NY Medicare	$8.53
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group	$13.90
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO	$13.90
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$6.86
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp	$9.27
Rate for Payer: Cash Price	$13.91
Rate for Payer: CDPHP Commercial	$14.92
Rate for Payer: CDPHP Medicare	$6.86
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$14.83
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$14.83
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$14.83
Rate for Payer: EmblemHealth Medicaid	$14.83
Rate for Payer: EmblemHealth Medicare	$6.30
Rate for Payer: EmblemHealth Select Care	$13.35
Rate for Payer: Fidelis Medicare	$7.07
Rate for Payer: Galaxy Health Commercial	$12.05
Rate for Payer: Hamaspik Choice Medicare	$6.86
Rate for Payer: Humana Medicare	$6.86
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$12.98
Rate for Payer: Local 1199SEIU Medicare	$8.53
Rate for Payer: MVP Health Care of NY Commercial	$13.90
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$10.44
Rate for Payer: MVP Health Care of NY Medicare	$7.20
Rate for Payer: United Healthcare Medicare	$6.86
Rate for Payer: WellCare Medicare	$10.20

SODIUM CHLORIDE 0.9% 0.009 SDV 25X10ML

Facility

$6.18

Service Code	NDC 63323018610
Hospital Charge Code	4400710
Hospital Revenue Code	250
Min. Negotiated Rate	$2.10
Max. Negotiated Rate	$4.97
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) Blue Access/Small Group	$4.64
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO	$4.64
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$2.29
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp	$3.09
Rate for Payer: Cash Price	$4.64
Rate for Payer: CDPHP Commercial	$4.97
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	$2.36
Rate for Payer: Galaxy Health Commercial	$4.02
Rate for Payer: Hamaspik Choice Medicare	$2.29
Rate for Payer: Humana Medicare	$2.29
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	$4.64
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$3.48
Rate for Payer: MVP Health Care of NY Medicare	$2.40
Rate for Payer: United Healthcare Medicare	$2.29
Rate for Payer: WellCare Medicare	$3.40

SODIUM CHLORIDE 0.9% 0.009 SDV 25X10ML

Facility

$6.18

Service Code	NDC 63323018610
Hospital Charge Code	4400710
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

SODIUM CHLORIDE 0.9% INHALAT 0.009 AMIH

Facility

$6.18

Service Code	NDC 00487930103
Hospital Charge Code	4400708
Hospital Revenue Code	250
Min. Negotiated Rate	$2.10
Max. Negotiated Rate	$4.97
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) Blue Access/Small Group	$4.64
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO	$4.64
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$2.29
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp	$3.09
Rate for Payer: Cash Price	$4.64
Rate for Payer: CDPHP Commercial	$4.97
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	$2.36
Rate for Payer: Galaxy Health Commercial	$4.02
Rate for Payer: Hamaspik Choice Medicare	$2.29
Rate for Payer: Humana Medicare	$2.29
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	$4.64
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$3.48
Rate for Payer: MVP Health Care of NY Medicare	$2.40
Rate for Payer: United Healthcare Medicare	$2.29
Rate for Payer: WellCare Medicare	$3.40

SODIUM CHLORIDE 0.9% INHALAT 0.009 AMIH

Facility

$6.18

Service Code	NDC 00487930103
Hospital Charge Code	4400708
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

SODIUM CHLORIDE 0.9% SOLUTION 0.9 mg, 50 mL

Facility

$21.00

Service Code	NDC 00338055311
Hospital Charge Code	4401566
Hospital Revenue Code	250
Min. Negotiated Rate	$11.55
Max. Negotiated Rate	$13.65
Rate for Payer: Cash Price	$15.75
Rate for Payer: Galaxy Health Commercial	$13.65
Rate for Payer: WellCare Medicare	$11.55

SODIUM CHLORIDE 0.9% SOLUTION 0.9 mg, 50 mL

Facility

$21.00

Service Code	NDC 00338055311
Hospital Charge Code	4401566
Hospital Revenue Code	250
Min. Negotiated Rate	$7.14
Max. Negotiated Rate	$16.90
Rate for Payer: Aetna of NY Commercial	$14.70
Rate for Payer: Aetna of NY Medicare	$9.66
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group	$15.75
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO	$15.75
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$7.77
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp	$10.50
Rate for Payer: Cash Price	$15.75
Rate for Payer: CDPHP Commercial	$16.90
Rate for Payer: CDPHP Medicare	$7.77
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$16.80
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$16.80
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$16.80
Rate for Payer: EmblemHealth Medicaid	$16.80
Rate for Payer: EmblemHealth Medicare	$7.14
Rate for Payer: EmblemHealth Select Care	$15.12
Rate for Payer: Fidelis Medicare	$8.00
Rate for Payer: Galaxy Health Commercial	$13.65
Rate for Payer: Hamaspik Choice Medicare	$7.77
Rate for Payer: Humana Medicare	$7.77
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$14.70
Rate for Payer: Local 1199SEIU Medicare	$9.66
Rate for Payer: MVP Health Care of NY Commercial	$15.75
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$11.82
Rate for Payer: MVP Health Care of NY Medicare	$8.16
Rate for Payer: United Healthcare Medicare	$7.77
Rate for Payer: WellCare Medicare	$11.55

SODIUM CHLORIDE 1 G TAB

Facility

$6.18

Service Code	NDC 00223176001
Hospital Charge Code	4409033
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

SODIUM CHLORIDE 1 G TAB

Facility

$6.18

Service Code	NDC 00223176001
Hospital Charge Code	4409033
Hospital Revenue Code	250
Min. Negotiated Rate	$2.10
Max. Negotiated Rate	$4.97
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) Blue Access/Small Group	$4.64
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO	$4.64
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$2.29
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp	$3.09
Rate for Payer: Cash Price	$4.64
Rate for Payer: CDPHP Commercial	$4.97
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	$2.36
Rate for Payer: Galaxy Health Commercial	$4.02
Rate for Payer: Hamaspik Choice Medicare	$2.29
Rate for Payer: Humana Medicare	$2.29
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	$4.64
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$3.48
Rate for Payer: MVP Health Care of NY Medicare	$2.40
Rate for Payer: United Healthcare Medicare	$2.29
Rate for Payer: WellCare Medicare	$3.40

SODIUM CHLORIDE 3% 0.03 IVSL 24X500ML

Facility

$18.28

Service Code	NDC 00338005403
Hospital Charge Code	4450015
Hospital Revenue Code	250
Min. Negotiated Rate	$10.05
Max. Negotiated Rate	$11.88
Rate for Payer: Cash Price	$13.71
Rate for Payer: Galaxy Health Commercial	$11.88
Rate for Payer: WellCare Medicare	$10.05

SODIUM CHLORIDE 3% 0.03 IVSL 24X500ML

Facility

$18.28

Service Code	NDC 00338005403
Hospital Charge Code	4450015
Hospital Revenue Code	250
Min. Negotiated Rate	$6.22
Max. Negotiated Rate	$14.72
Rate for Payer: Aetna of NY Commercial	$12.80
Rate for Payer: Aetna of NY Medicare	$8.41
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group	$13.71
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO	$13.71
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$6.76
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp	$9.14
Rate for Payer: Cash Price	$13.71
Rate for Payer: CDPHP Commercial	$14.72
Rate for Payer: CDPHP Medicare	$6.76
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$14.62
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$14.62
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$14.62
Rate for Payer: EmblemHealth Medicaid	$14.62
Rate for Payer: EmblemHealth Medicare	$6.22
Rate for Payer: EmblemHealth Select Care	$13.16
Rate for Payer: Fidelis Medicare	$6.97
Rate for Payer: Galaxy Health Commercial	$11.88
Rate for Payer: Hamaspik Choice Medicare	$6.76
Rate for Payer: Humana Medicare	$6.76
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$12.80
Rate for Payer: Local 1199SEIU Medicare	$8.41
Rate for Payer: MVP Health Care of NY Commercial	$13.71
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$10.29
Rate for Payer: MVP Health Care of NY Medicare	$7.10
Rate for Payer: United Healthcare Medicare	$6.76
Rate for Payer: WellCare Medicare	$10.05

SODIUM PHOS MB/SODIUM PHOS DB ENMA 133

Facility

$6.18

Service Code	NDC 00536741551
Hospital Charge Code	4400298
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

Know your out-of-pocket cost for care.

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