Ellenville Regional Hospital

All Charges

Charge

Type

Setting

Price

STRIP IODOFORM PAC 1/4X5YD

Facility

$11.33

Hospital Charge Code	4471649
Hospital Revenue Code	270
Min. Negotiated Rate	$7.36
Max. Negotiated Rate	$7.36
Rate for Payer: Cash Price	$8.50
Rate for Payer: Galaxy Health Commercial	$7.36

STRIP IODOFORM PAC 1/4X5YD

Facility

$11.33

Hospital Charge Code	4471649
Hospital Revenue Code	270
Min. Negotiated Rate	$1.70
Max. Negotiated Rate	$9.06
Rate for Payer: Aetna of NY Commercial	$7.93
Rate for Payer: Aetna of NY Medicare	$5.21
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$4.53
Rate for Payer: Cash Price	$8.50
Rate for Payer: CDPHP Medicare	$4.19
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$9.06
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$9.06
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$9.06
Rate for Payer: EmblemHealth Medicaid	$9.06
Rate for Payer: EmblemHealth Medicare	$3.85
Rate for Payer: EmblemHealth Select Care	$8.16
Rate for Payer: Fidelis Medicare	$4.53
Rate for Payer: Galaxy Health Commercial	$7.36
Rate for Payer: Hamaspik Choice Medicare	$4.53
Rate for Payer: Humana Medicare	$4.53
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$7.93
Rate for Payer: Local 1199SEIU Medicare	$5.21
Rate for Payer: MVP Health Care of NY Commercial	$8.50
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$6.38
Rate for Payer: MVP Health Care of NY Medicare	$4.76
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$1.70
Rate for Payer: United Healthcare Medicare	$4.53
Rate for Payer: WellCare Medicare	$6.23

STRIP IODOFORM PAC 1"X5YD

Facility

$14.42

Hospital Charge Code	4471651
Hospital Revenue Code	270
Min. Negotiated Rate	$9.37
Max. Negotiated Rate	$9.37
Rate for Payer: Cash Price	$10.82
Rate for Payer: Galaxy Health Commercial	$9.37

STRIP IODOFORM PAC 1"X5YD

Facility

$14.42

Hospital Charge Code	4471651
Hospital Revenue Code	270
Min. Negotiated Rate	$2.16
Max. Negotiated Rate	$11.54
Rate for Payer: Aetna of NY Commercial	$10.09
Rate for Payer: Aetna of NY Medicare	$6.63
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$5.77
Rate for Payer: Cash Price	$10.82
Rate for Payer: CDPHP Medicare	$5.34
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$11.54
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$11.54
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$11.54
Rate for Payer: EmblemHealth Medicaid	$11.54
Rate for Payer: EmblemHealth Medicare	$4.90
Rate for Payer: EmblemHealth Select Care	$10.38
Rate for Payer: Fidelis Medicare	$5.77
Rate for Payer: Galaxy Health Commercial	$9.37
Rate for Payer: Hamaspik Choice Medicare	$5.77
Rate for Payer: Humana Medicare	$5.77
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$10.09
Rate for Payer: Local 1199SEIU Medicare	$6.63
Rate for Payer: MVP Health Care of NY Commercial	$10.81
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$8.12
Rate for Payer: MVP Health Care of NY Medicare	$6.06
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$2.16
Rate for Payer: United Healthcare Medicare	$5.77
Rate for Payer: WellCare Medicare	$7.93

STRIP IODOFORM PAC 2"X5YD

Facility

$19.57

Hospital Charge Code	4471652
Hospital Revenue Code	270
Min. Negotiated Rate	$2.94
Max. Negotiated Rate	$15.66
Rate for Payer: Aetna of NY Commercial	$13.70
Rate for Payer: Aetna of NY Medicare	$9.00
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$7.83
Rate for Payer: Cash Price	$14.68
Rate for Payer: CDPHP Medicare	$7.24
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$15.66
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$15.66
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$15.66
Rate for Payer: EmblemHealth Medicaid	$15.66
Rate for Payer: EmblemHealth Medicare	$6.65
Rate for Payer: EmblemHealth Select Care	$14.09
Rate for Payer: Fidelis Medicare	$7.83
Rate for Payer: Galaxy Health Commercial	$12.72
Rate for Payer: Hamaspik Choice Medicare	$7.83
Rate for Payer: Humana Medicare	$7.83
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$13.70
Rate for Payer: Local 1199SEIU Medicare	$9.00
Rate for Payer: MVP Health Care of NY Commercial	$14.68
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$11.02
Rate for Payer: MVP Health Care of NY Medicare	$8.22
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$2.94
Rate for Payer: United Healthcare Medicare	$7.83
Rate for Payer: WellCare Medicare	$10.76

STRIP IODOFORM PAC 2"X5YD

Facility

$19.57

Hospital Charge Code	4471652
Hospital Revenue Code	270
Min. Negotiated Rate	$12.72
Max. Negotiated Rate	$12.72
Rate for Payer: Cash Price	$14.68
Rate for Payer: Galaxy Health Commercial	$12.72

STRYKEFLOW II W/ TIP SUC/IRR

Facility

$339.90

Hospital Charge Code	4471233
Hospital Revenue Code	270
Min. Negotiated Rate	$50.98
Max. Negotiated Rate	$271.92
Rate for Payer: Aetna of NY Commercial	$237.93
Rate for Payer: Aetna of NY Medicare	$156.35
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$135.96
Rate for Payer: Cash Price	$254.92
Rate for Payer: CDPHP Medicare	$125.76
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$271.92
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$271.92
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$271.92
Rate for Payer: EmblemHealth Medicaid	$271.92
Rate for Payer: EmblemHealth Medicare	$115.57
Rate for Payer: EmblemHealth Select Care	$244.73
Rate for Payer: Fidelis Medicare	$135.96
Rate for Payer: Galaxy Health Commercial	$220.94
Rate for Payer: Hamaspik Choice Medicare	$135.96
Rate for Payer: Humana Medicare	$135.96
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$237.93
Rate for Payer: Local 1199SEIU Medicare	$156.35
Rate for Payer: MVP Health Care of NY Commercial	$254.93
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$191.36
Rate for Payer: MVP Health Care of NY Medicare	$142.76
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$50.98
Rate for Payer: United Healthcare Medicare	$135.96
Rate for Payer: WellCare Medicare	$186.94

STRYKEFLOW II W/ TIP SUC/IRR

Facility

$339.90

Hospital Charge Code	4471233
Hospital Revenue Code	270
Min. Negotiated Rate	$220.94
Max. Negotiated Rate	$220.94
Rate for Payer: Cash Price	$254.92
Rate for Payer: Galaxy Health Commercial	$220.94

STRYKER BATTERY PACK 9.6V

Facility

$1,549.12

Hospital Charge Code	4471353
Hospital Revenue Code	270
Min. Negotiated Rate	$232.37
Max. Negotiated Rate	$1,239.30
Rate for Payer: Aetna of NY Commercial	$1,084.38
Rate for Payer: Aetna of NY Medicare	$712.60
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$619.65
Rate for Payer: Cash Price	$1,161.84
Rate for Payer: CDPHP Medicare	$573.17
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$1,239.30
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$1,239.30
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$1,239.30
Rate for Payer: EmblemHealth Medicaid	$1,239.30
Rate for Payer: EmblemHealth Medicare	$526.70
Rate for Payer: EmblemHealth Select Care	$1,115.37
Rate for Payer: Fidelis Medicare	$619.65
Rate for Payer: Galaxy Health Commercial	$1,006.93
Rate for Payer: Hamaspik Choice Medicare	$619.65
Rate for Payer: Humana Medicare	$619.65
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$1,084.38
Rate for Payer: Local 1199SEIU Medicare	$712.60
Rate for Payer: MVP Health Care of NY Commercial	$1,161.84
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$872.15
Rate for Payer: MVP Health Care of NY Medicare	$650.63
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$232.37
Rate for Payer: United Healthcare Medicare	$619.65
Rate for Payer: WellCare Medicare	$852.02

STRYKER BATTERY PACK 9.6V

Facility

$1,549.12

Hospital Charge Code	4471353
Hospital Revenue Code	270
Min. Negotiated Rate	$1,006.93
Max. Negotiated Rate	$1,006.93
Rate for Payer: Cash Price	$1,161.84
Rate for Payer: Galaxy Health Commercial	$1,006.93

STRYKER CUTTING BLADE

Facility

$113.30

Hospital Charge Code	4479160
Hospital Revenue Code	270
Min. Negotiated Rate	$17.00
Max. Negotiated Rate	$90.64
Rate for Payer: Aetna of NY Commercial	$79.31
Rate for Payer: Aetna of NY Medicare	$52.12
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$45.32
Rate for Payer: Cash Price	$84.98
Rate for Payer: CDPHP Medicare	$41.92
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$90.64
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$90.64
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$90.64
Rate for Payer: EmblemHealth Medicaid	$90.64
Rate for Payer: EmblemHealth Medicare	$38.52
Rate for Payer: EmblemHealth Select Care	$81.58
Rate for Payer: Fidelis Medicare	$45.32
Rate for Payer: Galaxy Health Commercial	$73.64
Rate for Payer: Hamaspik Choice Medicare	$45.32
Rate for Payer: Humana Medicare	$45.32
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$79.31
Rate for Payer: Local 1199SEIU Medicare	$52.12
Rate for Payer: MVP Health Care of NY Commercial	$84.97
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$63.79
Rate for Payer: MVP Health Care of NY Medicare	$47.59
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$17.00
Rate for Payer: United Healthcare Medicare	$45.32
Rate for Payer: WellCare Medicare	$62.31

STRYKER CUTTING BLADE

Facility

$113.30

Hospital Charge Code	4479160
Hospital Revenue Code	270
Min. Negotiated Rate	$73.64
Max. Negotiated Rate	$73.64
Rate for Payer: Cash Price	$84.98
Rate for Payer: Galaxy Health Commercial	$73.64

SUBOXONE 12 MG-3 MG SL FILM 1 ea, 30 eaches

Facility

$60.00

Service Code	HCPCS J0575
Hospital Charge Code	4401342
Hospital Revenue Code	636
Min. Negotiated Rate	$9.00
Max. Negotiated Rate	$48.00
Rate for Payer: Aetna of NY Medicare	$27.60
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$24.00
Rate for Payer: Cash Price	$45.00
Rate for Payer: Cash Price	$45.00
Rate for Payer: CDPHP Medicare	$22.20
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$48.00
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$48.00
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$48.00
Rate for Payer: EmblemHealth Medicaid	$48.00
Rate for Payer: EmblemHealth Medicare	$20.40
Rate for Payer: EmblemHealth Select Care	$43.20
Rate for Payer: Fidelis Medicare	$24.00
Rate for Payer: Galaxy Health Commercial	$39.00
Rate for Payer: Hamaspik Choice Medicare	$24.00
Rate for Payer: Humana Medicare	$24.00
Rate for Payer: Local 1199SEIU Medicare	$27.60
Rate for Payer: MVP Health Care of NY Commercial	$45.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$33.78
Rate for Payer: MVP Health Care of NY Medicare	$25.20
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$30.18
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$9.00
Rate for Payer: United Healthcare Commercial	$30.18
Rate for Payer: United Healthcare Medicare	$24.00
Rate for Payer: WellCare Medicare	$33.00

SUBOXONE 12 MG-3 MG SL FILM 1 ea, 30 eaches

Facility

$60.00

Service Code	HCPCS J0575
Hospital Charge Code	4401342
Hospital Revenue Code	636
Min. Negotiated Rate	$33.00
Max. Negotiated Rate	$39.00
Rate for Payer: Aetna of NY Commercial	$33.00
Rate for Payer: Cash Price	$45.00
Rate for Payer: Galaxy Health Commercial	$39.00
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$33.00
Rate for Payer: WellCare Medicare	$33.00

SUBOXONE 2 MG-0.5 MG SL FILM 1 ea, 30 eaches

Facility

$17.00

Service Code	HCPCS J0574
Hospital Charge Code	4401338
Hospital Revenue Code	636
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$19.32
Rate for Payer: Aetna of NY Medicare	$7.82
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$6.80
Rate for Payer: Cash Price	$12.75
Rate for Payer: Cash Price	$12.75
Rate for Payer: CDPHP Medicare	$6.29
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$13.60
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$10.31
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$8.59
Rate for Payer: EmblemHealth Medicaid	$8.59
Rate for Payer: EmblemHealth Medicare	$5.78
Rate for Payer: EmblemHealth Select Care	$12.24
Rate for Payer: Fidelis Medicare	$6.80
Rate for Payer: Galaxy Health Commercial	$11.05
Rate for Payer: Galaxy Health Workers Comp	$8.42
Rate for Payer: Hamaspik Choice Medicaid	$8.59
Rate for Payer: Hamaspik Choice Medicare	$6.80
Rate for Payer: Humana Medicare	$6.80
Rate for Payer: Local 1199SEIU Medicare	$7.82
Rate for Payer: MVP Health Care of NY Child Health Plus/Family Health Plus/HARP/Medicaid	$9.02
Rate for Payer: MVP Health Care of NY Commercial	$12.75
Rate for Payer: MVP Health Care of NY Essential Plan 1&2	$18.47
Rate for Payer: MVP Health Care of NY Essential Plan 3&4	$18.47
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$9.57
Rate for Payer: MVP Health Care of NY Medicare	$7.14
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$19.32
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$2.55
Rate for Payer: United Healthcare Commercial	$19.32
Rate for Payer: United Healthcare Medicare	$6.80
Rate for Payer: WellCare Child Health Plus/Family Health Plus/Medicaid	$9.02
Rate for Payer: WellCare Medicare	$9.35

SUBOXONE 2 MG-0.5 MG SL FILM 1 ea, 30 eaches

Facility

$17.00

Service Code	HCPCS J0574
Hospital Charge Code	4401338
Hospital Revenue Code	636
Min. Negotiated Rate	$9.35
Max. Negotiated Rate	$11.05
Rate for Payer: Aetna of NY Commercial	$9.35
Rate for Payer: Cash Price	$12.75
Rate for Payer: Galaxy Health Commercial	$11.05
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$9.35
Rate for Payer: WellCare Medicare	$9.35

SUBOXONE 4 MG-1 MG SL FILM 1 ea, 30 eaches

Facility

$30.00

Service Code	HCPCS J0573
Hospital Charge Code	4401341
Hospital Revenue Code	636
Min. Negotiated Rate	$4.50
Max. Negotiated Rate	$24.00
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: 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	$7.30
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$6.08
Rate for Payer: EmblemHealth Medicaid	$6.08
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: Galaxy Health Workers Comp	$5.96
Rate for Payer: Hamaspik Choice Medicaid	$6.08
Rate for Payer: Hamaspik Choice Medicare	$12.00
Rate for Payer: Humana Medicare	$12.00
Rate for Payer: Local 1199SEIU Medicare	$13.80
Rate for Payer: MVP Health Care of NY Child Health Plus/Family Health Plus/HARP/Medicaid	$6.38
Rate for Payer: MVP Health Care of NY Commercial	$22.50
Rate for Payer: MVP Health Care of NY Essential Plan 1&2	$13.07
Rate for Payer: MVP Health Care of NY Essential Plan 3&4	$13.07
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: Oxford Health Plans Freedom/Liberty/Metro	$18.63
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$4.50
Rate for Payer: United Healthcare Commercial	$18.63
Rate for Payer: United Healthcare Medicare	$12.00
Rate for Payer: WellCare Child Health Plus/Family Health Plus/Medicaid	$6.38
Rate for Payer: WellCare Medicare	$16.50

SUBOXONE 4 MG-1 MG SL FILM 1 ea, 30 eaches

Facility

$30.00

Service Code	HCPCS J0573
Hospital Charge Code	4401341
Hospital Revenue Code	636
Min. Negotiated Rate	$16.50
Max. Negotiated Rate	$19.50
Rate for Payer: Aetna of NY Commercial	$16.50
Rate for Payer: Cash Price	$22.50
Rate for Payer: Galaxy Health Commercial	$19.50
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$16.50
Rate for Payer: WellCare Medicare	$16.50

SUBOXONE 8 MG-2 MG SL FILM 1 ea, 30 eaches

Facility

$30.00

Service Code	HCPCS J0574
Hospital Charge Code	4401337
Hospital Revenue Code	636
Min. Negotiated Rate	$4.50
Max. Negotiated Rate	$24.00
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: 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	$10.31
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$8.59
Rate for Payer: EmblemHealth Medicaid	$8.59
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: Galaxy Health Workers Comp	$8.42
Rate for Payer: Hamaspik Choice Medicaid	$8.59
Rate for Payer: Hamaspik Choice Medicare	$12.00
Rate for Payer: Humana Medicare	$12.00
Rate for Payer: Local 1199SEIU Medicare	$13.80
Rate for Payer: MVP Health Care of NY Child Health Plus/Family Health Plus/HARP/Medicaid	$9.02
Rate for Payer: MVP Health Care of NY Commercial	$22.50
Rate for Payer: MVP Health Care of NY Essential Plan 1&2	$18.47
Rate for Payer: MVP Health Care of NY Essential Plan 3&4	$18.47
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: Oxford Health Plans Freedom/Liberty/Metro	$19.32
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$4.50
Rate for Payer: United Healthcare Commercial	$19.32
Rate for Payer: United Healthcare Medicare	$12.00
Rate for Payer: WellCare Child Health Plus/Family Health Plus/Medicaid	$9.02
Rate for Payer: WellCare Medicare	$16.50

SUBOXONE 8 MG-2 MG SL FILM 1 ea, 30 eaches

Facility

$30.00

Service Code	HCPCS J0574
Hospital Charge Code	4401337
Hospital Revenue Code	636
Min. Negotiated Rate	$16.50
Max. Negotiated Rate	$19.50
Rate for Payer: Aetna of NY Commercial	$16.50
Rate for Payer: Cash Price	$22.50
Rate for Payer: Galaxy Health Commercial	$19.50
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$16.50
Rate for Payer: WellCare Medicare	$16.50

SUCCINYLCHOLINE CHLORIDE, UP TO 20 MG

Facility

$6.91

Service Code	HCPCS J0330
Hospital Charge Code	4400675
Hospital Revenue Code	636
Min. Negotiated Rate	$1.04
Max. Negotiated Rate	$5.53
Rate for Payer: Aetna of NY Medicare	$3.18
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$2.76
Rate for Payer: Cash Price	$5.18
Rate for Payer: Cash Price	$5.18
Rate for Payer: CDPHP Medicare	$2.56
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$5.53
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$5.53
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$5.53
Rate for Payer: EmblemHealth Medicaid	$5.53
Rate for Payer: EmblemHealth Medicare	$2.35
Rate for Payer: EmblemHealth Select Care	$4.98
Rate for Payer: Fidelis Medicare	$2.76
Rate for Payer: Galaxy Health Commercial	$4.49
Rate for Payer: Hamaspik Choice Medicare	$2.76
Rate for Payer: Humana Medicare	$2.76
Rate for Payer: Local 1199SEIU Medicare	$3.18
Rate for Payer: MVP Health Care of NY Commercial	$5.18
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$3.89
Rate for Payer: MVP Health Care of NY Medicare	$2.90
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$2.87
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$1.04
Rate for Payer: United Healthcare Commercial	$2.87
Rate for Payer: United Healthcare Medicare	$2.76
Rate for Payer: WellCare Medicare	$3.80

SUCCINYLCHOLINE CHLORIDE, UP TO 20 MG

Facility

$6.91

Service Code	HCPCS J0330
Hospital Charge Code	4400675
Hospital Revenue Code	636
Min. Negotiated Rate	$3.80
Max. Negotiated Rate	$4.49
Rate for Payer: Aetna of NY Commercial	$3.80
Rate for Payer: Cash Price	$5.18
Rate for Payer: Galaxy Health Commercial	$4.49
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$3.80
Rate for Payer: WellCare Medicare	$3.80

SUCRALFATE 1GM TABS 10X10EA

Facility

$6.18

Service Code	NDC 51079075301
Hospital Charge Code	4400724
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

SUCRALFATE 1GM TABS 10X10EA

Facility

$6.18

Service Code	NDC 51079075301
Hospital Charge Code	4400724
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

SUCRALFATE SUSP

Facility

$24.21

Service Code	NDC 66689079050
Hospital Charge Code	4408976
Hospital Revenue Code	250
Min. Negotiated Rate	$13.32
Max. Negotiated Rate	$15.74
Rate for Payer: Cash Price	$18.16
Rate for Payer: Galaxy Health Commercial	$15.74
Rate for Payer: WellCare Medicare	$13.32

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