Ellenville Regional Hospital

All Charges

Charge

Type

Setting

Price

US VEIN EXTREMITY UPPER LEFT

Facility

$731.00

Service Code	HCPCS 93970 LT
Hospital Charge Code	4201033
Hospital Revenue Code	921
Min. Negotiated Rate	$475.15
Max. Negotiated Rate	$475.15
Rate for Payer: Cash Price	$548.25
Rate for Payer: Galaxy Health Commercial	$475.15

US VEIN EXTREMITY UPPER LEFT

Facility

$731.00

Service Code	HCPCS 93970 LT
Hospital Charge Code	4201033
Hospital Revenue Code	921
Min. Negotiated Rate	$109.65
Max. Negotiated Rate	$584.80
Rate for Payer: Aetna of NY Commercial	$475.15
Rate for Payer: Aetna of NY Medicare	$336.26
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$292.40
Rate for Payer: Cash Price	$548.25
Rate for Payer: Cash Price	$548.25
Rate for Payer: CDPHP Medicare	$270.47
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$511.70
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$584.80
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$584.80
Rate for Payer: EmblemHealth Medicaid	$584.80
Rate for Payer: EmblemHealth Medicare	$248.54
Rate for Payer: EmblemHealth Select Care	$475.15
Rate for Payer: Fidelis Medicare	$292.40
Rate for Payer: Galaxy Health Commercial	$475.15
Rate for Payer: Hamaspik Choice Medicare	$292.40
Rate for Payer: Humana Medicare	$292.40
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$475.15
Rate for Payer: Local 1199SEIU Medicare	$336.26
Rate for Payer: MVP Health Care of NY Commercial	$548.25
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$411.55
Rate for Payer: MVP Health Care of NY Medicare	$307.02
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$287.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$109.65
Rate for Payer: United Healthcare Commercial	$287.00
Rate for Payer: United Healthcare Medicare	$292.40
Rate for Payer: WellCare Medicare	$402.05

US VEIN EXTREMITY UPPER, LEFT

Facility

$100.00

Service Code	HCPCS 93970 26,LT
Hospital Charge Code	5201033
Hospital Revenue Code	960
Min. Negotiated Rate	$15.00
Max. Negotiated Rate	$80.00
Rate for Payer: Aetna of NY Commercial	$65.00
Rate for Payer: Aetna of NY Medicare	$46.00
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$40.00
Rate for Payer: Cash Price	$75.00
Rate for Payer: CDPHP Medicare	$37.00
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$80.00
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$80.00
Rate for Payer: EmblemHealth Medicaid	$80.00
Rate for Payer: EmblemHealth Medicare	$34.00
Rate for Payer: Fidelis Medicare	$40.00
Rate for Payer: Galaxy Health Commercial	$65.00
Rate for Payer: Hamaspik Choice Medicare	$40.00
Rate for Payer: Humana Medicare	$40.00
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$65.00
Rate for Payer: Local 1199SEIU Medicare	$46.00
Rate for Payer: MVP Health Care of NY Commercial	$75.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$56.30
Rate for Payer: MVP Health Care of NY Medicare	$42.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$15.00
Rate for Payer: United Healthcare Medicare	$40.00
Rate for Payer: WellCare Medicare	$55.00

US VEIN EXTREMITY UPPER, LEFT

Facility

$100.00

Service Code	HCPCS 93970 26,LT
Hospital Charge Code	5201033
Hospital Revenue Code	960
Min. Negotiated Rate	$65.00
Max. Negotiated Rate	$65.00
Rate for Payer: Cash Price	$75.00
Rate for Payer: Galaxy Health Commercial	$65.00

US VEIN EXTREMITY UPPER RIGHT

Facility

$731.00

Service Code	HCPCS 93970 RT
Hospital Charge Code	4201034
Hospital Revenue Code	921
Min. Negotiated Rate	$109.65
Max. Negotiated Rate	$584.80
Rate for Payer: Aetna of NY Commercial	$475.15
Rate for Payer: Aetna of NY Medicare	$336.26
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$292.40
Rate for Payer: Cash Price	$548.25
Rate for Payer: Cash Price	$548.25
Rate for Payer: CDPHP Medicare	$270.47
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$511.70
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$584.80
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$584.80
Rate for Payer: EmblemHealth Medicaid	$584.80
Rate for Payer: EmblemHealth Medicare	$248.54
Rate for Payer: EmblemHealth Select Care	$475.15
Rate for Payer: Fidelis Medicare	$292.40
Rate for Payer: Galaxy Health Commercial	$475.15
Rate for Payer: Hamaspik Choice Medicare	$292.40
Rate for Payer: Humana Medicare	$292.40
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$475.15
Rate for Payer: Local 1199SEIU Medicare	$336.26
Rate for Payer: MVP Health Care of NY Commercial	$548.25
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$411.55
Rate for Payer: MVP Health Care of NY Medicare	$307.02
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$287.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$109.65
Rate for Payer: United Healthcare Commercial	$287.00
Rate for Payer: United Healthcare Medicare	$292.40
Rate for Payer: WellCare Medicare	$402.05

US VEIN EXTREMITY UPPER RIGHT

Facility

$731.00

Service Code	HCPCS 93970 RT
Hospital Charge Code	4201034
Hospital Revenue Code	921
Min. Negotiated Rate	$475.15
Max. Negotiated Rate	$475.15
Rate for Payer: Cash Price	$548.25
Rate for Payer: Galaxy Health Commercial	$475.15

US VEIN EXTREMITY UPPER, RIGHT

Facility

$100.00

Service Code	HCPCS 93970 26,RT
Hospital Charge Code	5201034
Hospital Revenue Code	960
Min. Negotiated Rate	$15.00
Max. Negotiated Rate	$80.00
Rate for Payer: Aetna of NY Commercial	$65.00
Rate for Payer: Aetna of NY Medicare	$46.00
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$40.00
Rate for Payer: Cash Price	$75.00
Rate for Payer: CDPHP Medicare	$37.00
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$80.00
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$80.00
Rate for Payer: EmblemHealth Medicaid	$80.00
Rate for Payer: EmblemHealth Medicare	$34.00
Rate for Payer: Fidelis Medicare	$40.00
Rate for Payer: Galaxy Health Commercial	$65.00
Rate for Payer: Hamaspik Choice Medicare	$40.00
Rate for Payer: Humana Medicare	$40.00
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$65.00
Rate for Payer: Local 1199SEIU Medicare	$46.00
Rate for Payer: MVP Health Care of NY Commercial	$75.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$56.30
Rate for Payer: MVP Health Care of NY Medicare	$42.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$15.00
Rate for Payer: United Healthcare Medicare	$40.00
Rate for Payer: WellCare Medicare	$55.00

US VEIN EXTREMITY UPPER, RIGHT

Facility

$100.00

Service Code	HCPCS 93970 26,RT
Hospital Charge Code	5201034
Hospital Revenue Code	960
Min. Negotiated Rate	$65.00
Max. Negotiated Rate	$65.00
Rate for Payer: Cash Price	$75.00
Rate for Payer: Galaxy Health Commercial	$65.00

US VEIN EXTREMITY UPPER UNILAT

Facility

$320.00

Service Code	HCPCS 93971
Hospital Charge Code	4200030
Hospital Revenue Code	921
Min. Negotiated Rate	$208.00
Max. Negotiated Rate	$208.00
Rate for Payer: Cash Price	$240.00
Rate for Payer: Galaxy Health Commercial	$208.00

US VEIN EXTREMITY UPPER UNILAT

Facility

$65.00

Service Code	HCPCS 93971 26
Hospital Charge Code	5200030
Hospital Revenue Code	960
Min. Negotiated Rate	$42.25
Max. Negotiated Rate	$42.25
Rate for Payer: Cash Price	$48.75
Rate for Payer: Galaxy Health Commercial	$42.25

US VEIN EXTREMITY UPPER UNILAT

Facility

$65.00

Service Code	HCPCS 93971 26
Hospital Charge Code	5200030
Hospital Revenue Code	960
Min. Negotiated Rate	$9.75
Max. Negotiated Rate	$52.00
Rate for Payer: Aetna of NY Commercial	$42.25
Rate for Payer: Aetna of NY Medicare	$29.90
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$26.00
Rate for Payer: Cash Price	$48.75
Rate for Payer: CDPHP Medicare	$24.05
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$52.00
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$52.00
Rate for Payer: EmblemHealth Medicaid	$52.00
Rate for Payer: EmblemHealth Medicare	$22.10
Rate for Payer: Fidelis Medicare	$26.00
Rate for Payer: Galaxy Health Commercial	$42.25
Rate for Payer: Hamaspik Choice Medicare	$26.00
Rate for Payer: Humana Medicare	$26.00
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$42.25
Rate for Payer: Local 1199SEIU Medicare	$29.90
Rate for Payer: MVP Health Care of NY Commercial	$48.75
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$36.59
Rate for Payer: MVP Health Care of NY Medicare	$27.30
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$9.75
Rate for Payer: United Healthcare Medicare	$26.00
Rate for Payer: WellCare Medicare	$35.75

US VEIN EXTREMITY UPPER UNILAT

Facility

$320.00

Service Code	HCPCS 93971
Hospital Charge Code	4200030
Hospital Revenue Code	921
Min. Negotiated Rate	$48.00
Max. Negotiated Rate	$287.00
Rate for Payer: Aetna of NY Commercial	$208.00
Rate for Payer: Aetna of NY Medicare	$147.20
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$128.00
Rate for Payer: Cash Price	$240.00
Rate for Payer: Cash Price	$240.00
Rate for Payer: CDPHP Medicare	$118.40
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$224.00
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$256.00
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$256.00
Rate for Payer: EmblemHealth Medicaid	$256.00
Rate for Payer: EmblemHealth Medicare	$108.80
Rate for Payer: EmblemHealth Select Care	$208.00
Rate for Payer: Fidelis Medicare	$128.00
Rate for Payer: Galaxy Health Commercial	$208.00
Rate for Payer: Hamaspik Choice Medicare	$128.00
Rate for Payer: Humana Medicare	$128.00
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$208.00
Rate for Payer: Local 1199SEIU Medicare	$147.20
Rate for Payer: MVP Health Care of NY Commercial	$240.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$180.16
Rate for Payer: MVP Health Care of NY Medicare	$134.40
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$287.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$48.00
Rate for Payer: United Healthcare Commercial	$287.00
Rate for Payer: United Healthcare Medicare	$128.00
Rate for Payer: WellCare Medicare	$176.00

US XTR NON-VASC LMTD

Facility

$102.00

Service Code	HCPCS 76882 26
Hospital Charge Code	5201046
Hospital Revenue Code	960
Min. Negotiated Rate	$15.30
Max. Negotiated Rate	$81.60
Rate for Payer: Aetna of NY Commercial	$71.40
Rate for Payer: Aetna of NY Medicare	$46.92
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$40.80
Rate for Payer: Cash Price	$76.50
Rate for Payer: CDPHP Medicare	$37.74
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$81.60
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$81.60
Rate for Payer: EmblemHealth Medicaid	$81.60
Rate for Payer: EmblemHealth Medicare	$34.68
Rate for Payer: Fidelis Medicare	$40.80
Rate for Payer: Galaxy Health Commercial	$66.30
Rate for Payer: Hamaspik Choice Medicare	$40.80
Rate for Payer: Humana Medicare	$40.80
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$71.40
Rate for Payer: Local 1199SEIU Medicare	$46.92
Rate for Payer: MVP Health Care of NY Commercial	$76.50
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$57.43
Rate for Payer: MVP Health Care of NY Medicare	$42.84
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$15.30
Rate for Payer: United Healthcare Medicare	$40.80
Rate for Payer: WellCare Medicare	$56.10

US XTR NON-VASC LMTD

Facility

$320.00

Service Code	HCPCS 76882
Hospital Charge Code	4201046
Hospital Revenue Code	402
Min. Negotiated Rate	$48.00
Max. Negotiated Rate	$489.00
Rate for Payer: Aetna of NY Commercial	$224.00
Rate for Payer: Aetna of NY Medicare	$147.20
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$128.00
Rate for Payer: Cash Price	$240.00
Rate for Payer: Cash Price	$240.00
Rate for Payer: CDPHP Medicare	$118.40
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$224.00
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$256.00
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$256.00
Rate for Payer: EmblemHealth Medicaid	$256.00
Rate for Payer: EmblemHealth Medicare	$108.80
Rate for Payer: EmblemHealth Select Care	$208.00
Rate for Payer: Fidelis Medicare	$128.00
Rate for Payer: Galaxy Health Commercial	$208.00
Rate for Payer: Hamaspik Choice Medicare	$128.00
Rate for Payer: Humana Medicare	$128.00
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$224.00
Rate for Payer: Local 1199SEIU Medicare	$147.20
Rate for Payer: MVP Health Care of NY Commercial	$240.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$180.16
Rate for Payer: MVP Health Care of NY Medicare	$134.40
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$489.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$48.00
Rate for Payer: United Healthcare Commercial	$489.00
Rate for Payer: United Healthcare Medicare	$128.00
Rate for Payer: WellCare Medicare	$176.00

US XTR NON-VASC LMTD

Facility

$102.00

Service Code	HCPCS 76882 26
Hospital Charge Code	5201046
Hospital Revenue Code	960
Min. Negotiated Rate	$66.30
Max. Negotiated Rate	$66.30
Rate for Payer: Cash Price	$76.50
Rate for Payer: Galaxy Health Commercial	$66.30

US XTR NON-VASC LMTD

Facility

$320.00

Service Code	HCPCS 76882
Hospital Charge Code	4201046
Hospital Revenue Code	402
Min. Negotiated Rate	$208.00
Max. Negotiated Rate	$208.00
Rate for Payer: Cash Price	$240.00
Rate for Payer: Galaxy Health Commercial	$208.00

VAGINAL DELIVERY AFTER CESAREAN DELIVERY

Facility

$9,922.00

Service Code	HCPCS 59612
Hospital Charge Code	4601198
Hospital Revenue Code	450
Min. Negotiated Rate	$925.00
Max. Negotiated Rate	$7,937.60
Rate for Payer: Aetna of NY Commercial	$1,000.00
Rate for Payer: Aetna of NY Medicare	$4,564.12
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$3,968.80
Rate for Payer: Cash Price	$7,441.50
Rate for Payer: Cash Price	$7,441.50
Rate for Payer: Cash Price	$7,441.50
Rate for Payer: CDPHP Medicare	$3,671.14
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$1,206.00
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$7,937.60
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$7,937.60
Rate for Payer: EmblemHealth Medicaid	$7,937.60
Rate for Payer: EmblemHealth Medicare	$3,373.48
Rate for Payer: EmblemHealth Select Care	$1,085.00
Rate for Payer: Fidelis Medicare	$3,968.80
Rate for Payer: Galaxy Health Commercial	$6,449.30
Rate for Payer: Hamaspik Choice Medicare	$3,968.80
Rate for Payer: Humana Medicare	$3,968.80
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$1,000.00
Rate for Payer: Local 1199SEIU Medicare	$4,564.12
Rate for Payer: MVP Health Care of NY Commercial	$1,234.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$925.00
Rate for Payer: MVP Health Care of NY Medicare	$4,167.24
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$1,009.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$1,488.30
Rate for Payer: United Healthcare Commercial	$1,009.00
Rate for Payer: United Healthcare Medicare	$3,968.80
Rate for Payer: WellCare Medicare	$5,457.10

VAGINAL DELIVERY AFTER CESAREAN DELIVERY

Facility

$9,922.00

Service Code	HCPCS 59612
Hospital Charge Code	4601198
Hospital Revenue Code	450
Min. Negotiated Rate	$6,449.30
Max. Negotiated Rate	$6,449.30
Rate for Payer: Cash Price	$7,441.50
Rate for Payer: Galaxy Health Commercial	$6,449.30

VAGINAL DELIVERY ONLY

Facility

$9,922.00

Service Code	HCPCS 59409
Hospital Charge Code	4609613
Hospital Revenue Code	450
Min. Negotiated Rate	$6,449.30
Max. Negotiated Rate	$6,449.30
Rate for Payer: Cash Price	$7,441.50
Rate for Payer: Galaxy Health Commercial	$6,449.30

VAGINAL DELIVERY ONLY

Facility

$9,922.00

Service Code	HCPCS 59409
Hospital Charge Code	4609613
Hospital Revenue Code	450
Min. Negotiated Rate	$925.00
Max. Negotiated Rate	$7,937.60
Rate for Payer: Aetna of NY Commercial	$1,000.00
Rate for Payer: Aetna of NY Medicare	$4,564.12
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$3,968.80
Rate for Payer: Cash Price	$7,441.50
Rate for Payer: Cash Price	$7,441.50
Rate for Payer: Cash Price	$7,441.50
Rate for Payer: CDPHP Medicare	$3,671.14
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$1,206.00
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$7,937.60
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$7,937.60
Rate for Payer: EmblemHealth Medicaid	$7,937.60
Rate for Payer: EmblemHealth Medicare	$3,373.48
Rate for Payer: EmblemHealth Select Care	$1,085.00
Rate for Payer: Fidelis Medicare	$3,968.80
Rate for Payer: Galaxy Health Commercial	$6,449.30
Rate for Payer: Hamaspik Choice Medicare	$3,968.80
Rate for Payer: Humana Medicare	$3,968.80
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$1,000.00
Rate for Payer: Local 1199SEIU Medicare	$4,564.12
Rate for Payer: MVP Health Care of NY Commercial	$1,234.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$925.00
Rate for Payer: MVP Health Care of NY Medicare	$4,167.24
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$1,009.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$1,488.30
Rate for Payer: United Healthcare Commercial	$1,009.00
Rate for Payer: United Healthcare Medicare	$3,968.80
Rate for Payer: WellCare Medicare	$5,457.10

VALACYCLOVIR HCL 500MG TABS 30 EA

Facility

$22.40

Service Code	NDC 51079009303
Hospital Charge Code	4400785
Hospital Revenue Code	250
Min. Negotiated Rate	$3.36
Max. Negotiated Rate	$17.92
Rate for Payer: Aetna of NY Commercial	$15.68
Rate for Payer: Aetna of NY Medicare	$10.30
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$8.96
Rate for Payer: Cash Price	$16.80
Rate for Payer: CDPHP Medicare	$8.29
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$17.92
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$17.92
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$17.92
Rate for Payer: EmblemHealth Medicaid	$17.92
Rate for Payer: EmblemHealth Medicare	$7.62
Rate for Payer: EmblemHealth Select Care	$16.13
Rate for Payer: Fidelis Medicare	$8.96
Rate for Payer: Galaxy Health Commercial	$14.56
Rate for Payer: Hamaspik Choice Medicare	$8.96
Rate for Payer: Humana Medicare	$8.96
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$15.68
Rate for Payer: Local 1199SEIU Medicare	$10.30
Rate for Payer: MVP Health Care of NY Commercial	$16.80
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$12.61
Rate for Payer: MVP Health Care of NY Medicare	$9.41
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$3.36
Rate for Payer: United Healthcare Medicare	$8.96
Rate for Payer: WellCare Medicare	$12.32

VALACYCLOVIR HCL 500MG TABS 30 EA

Facility

$22.40

Service Code	NDC 51079009303
Hospital Charge Code	4400785
Hospital Revenue Code	250
Min. Negotiated Rate	$12.32
Max. Negotiated Rate	$14.56
Rate for Payer: Cash Price	$16.80
Rate for Payer: Galaxy Health Commercial	$14.56
Rate for Payer: WellCare Medicare	$12.32

valGANciclovir 450 MG TABLET 450 mg, 60 eaches

Facility

$12.00

Service Code	NDC 31722083260
Hospital Charge Code	4401483
Hospital Revenue Code	250
Min. Negotiated Rate	$6.60
Max. Negotiated Rate	$7.80
Rate for Payer: Cash Price	$9.00
Rate for Payer: Galaxy Health Commercial	$7.80
Rate for Payer: WellCare Medicare	$6.60

valGANciclovir 450 MG TABLET 450 mg, 60 eaches

Facility

$12.00

Service Code	NDC 31722083260
Hospital Charge Code	4401483
Hospital Revenue Code	250
Min. Negotiated Rate	$1.80
Max. Negotiated Rate	$9.60
Rate for Payer: Aetna of NY Commercial	$8.40
Rate for Payer: Aetna of NY Medicare	$5.52
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$4.80
Rate for Payer: Cash Price	$9.00
Rate for Payer: CDPHP Medicare	$4.44
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$9.60
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$9.60
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$9.60
Rate for Payer: EmblemHealth Medicaid	$9.60
Rate for Payer: EmblemHealth Medicare	$4.08
Rate for Payer: EmblemHealth Select Care	$8.64
Rate for Payer: Fidelis Medicare	$4.80
Rate for Payer: Galaxy Health Commercial	$7.80
Rate for Payer: Hamaspik Choice Medicare	$4.80
Rate for Payer: Humana Medicare	$4.80
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$8.40
Rate for Payer: Local 1199SEIU Medicare	$5.52
Rate for Payer: MVP Health Care of NY Commercial	$9.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$6.76
Rate for Payer: MVP Health Care of NY Medicare	$5.04
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$1.80
Rate for Payer: United Healthcare Medicare	$4.80
Rate for Payer: WellCare Medicare	$6.60

VALPOIC ACID SYP 250 MG / 5 ML

Facility

$6.18

Service Code	NDC 121467505
Hospital Charge Code	4408974
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.

All Charges