Ellenville Regional Hospital

All Charges

Charge

Type

Setting

Price

VICTOZA 3-PAK 18 MG/3 ML PEN 1 ea, 3 mL

Facility

$1,162.00

Service Code	NDC 169406013
Hospital Charge Code	4401414
Hospital Revenue Code	250
Min. Negotiated Rate	$639.10
Max. Negotiated Rate	$755.30
Rate for Payer: Cash Price	$871.50
Rate for Payer: Galaxy Health Commercial	$755.30
Rate for Payer: WellCare Medicare	$639.10

VIREAD 300 MG TABLET

Facility

$105.00

Service Code	NDC 61958040101
Hospital Charge Code	4401289
Hospital Revenue Code	250
Min. Negotiated Rate	$15.75
Max. Negotiated Rate	$84.00
Rate for Payer: Aetna of NY Commercial	$73.50
Rate for Payer: Aetna of NY Medicare	$48.30
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$42.00
Rate for Payer: Cash Price	$78.75
Rate for Payer: CDPHP Medicare	$38.85
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$84.00
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$84.00
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$84.00
Rate for Payer: EmblemHealth Medicaid	$84.00
Rate for Payer: EmblemHealth Medicare	$35.70
Rate for Payer: EmblemHealth Select Care	$75.60
Rate for Payer: Fidelis Medicare	$42.00
Rate for Payer: Galaxy Health Commercial	$68.25
Rate for Payer: Hamaspik Choice Medicare	$42.00
Rate for Payer: Humana Medicare	$42.00
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$73.50
Rate for Payer: Local 1199SEIU Medicare	$48.30
Rate for Payer: MVP Health Care of NY Commercial	$78.75
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$59.12
Rate for Payer: MVP Health Care of NY Medicare	$44.10
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$15.75
Rate for Payer: United Healthcare Medicare	$42.00
Rate for Payer: WellCare Medicare	$57.75

VIREAD 300 MG TABLET

Facility

$105.00

Service Code	NDC 61958040101
Hospital Charge Code	4401289
Hospital Revenue Code	250
Min. Negotiated Rate	$57.75
Max. Negotiated Rate	$68.25
Rate for Payer: Cash Price	$78.75
Rate for Payer: Galaxy Health Commercial	$68.25
Rate for Payer: WellCare Medicare	$57.75

VIRUS ISOL SHELL VIAL TECHN

Facility

$59.00

Service Code	HCPCS 87254
Hospital Charge Code	4304877
Hospital Revenue Code	306
Min. Negotiated Rate	$38.35
Max. Negotiated Rate	$38.35
Rate for Payer: Cash Price	$44.25
Rate for Payer: Galaxy Health Commercial	$38.35

VIRUS ISOL SHELL VIAL TECHN

Facility

$59.00

Service Code	HCPCS 87254
Hospital Charge Code	4304877
Hospital Revenue Code	306
Min. Negotiated Rate	$8.85
Max. Negotiated Rate	$47.20
Rate for Payer: Aetna of NY Commercial	$38.35
Rate for Payer: Aetna of NY Medicare	$27.14
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$23.60
Rate for Payer: Cash Price	$44.25
Rate for Payer: CDPHP Medicare	$21.83
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$35.40
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$47.20
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$47.20
Rate for Payer: EmblemHealth Medicaid	$47.20
Rate for Payer: EmblemHealth Medicare	$20.06
Rate for Payer: EmblemHealth Select Care	$35.40
Rate for Payer: Fidelis Medicare	$23.60
Rate for Payer: Galaxy Health Commercial	$38.35
Rate for Payer: Hamaspik Choice Medicare	$23.60
Rate for Payer: Humana Medicare	$23.60
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$38.35
Rate for Payer: Local 1199SEIU Medicare	$27.14
Rate for Payer: MVP Health Care of NY Commercial	$44.25
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$33.22
Rate for Payer: MVP Health Care of NY Medicare	$24.78
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$44.25
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$8.85
Rate for Payer: United Healthcare Commercial	$44.25
Rate for Payer: United Healthcare Medicare	$23.60
Rate for Payer: WellCare Medicare	$32.45

VITA B COMPLEX CAPS 100 EA

Facility

$6.18

Service Code	NDC 536478701
Hospital Charge Code	4400802
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

VITA B COMPLEX CAPS 100 EA

Facility

$6.18

Service Code	NDC 536478701
Hospital Charge Code	4400802
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

VITAMIN B1

Facility

$64.00

Service Code	HCPCS 84425
Hospital Charge Code	4300832
Hospital Revenue Code	301
Min. Negotiated Rate	$9.60
Max. Negotiated Rate	$51.20
Rate for Payer: Aetna of NY Commercial	$41.60
Rate for Payer: Aetna of NY Medicare	$29.44
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$25.60
Rate for Payer: Cash Price	$48.00
Rate for Payer: CDPHP Medicare	$23.68
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$38.40
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$51.20
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$51.20
Rate for Payer: EmblemHealth Medicaid	$51.20
Rate for Payer: EmblemHealth Medicare	$21.76
Rate for Payer: EmblemHealth Select Care	$38.40
Rate for Payer: Fidelis Medicare	$25.60
Rate for Payer: Galaxy Health Commercial	$41.60
Rate for Payer: Hamaspik Choice Medicare	$25.60
Rate for Payer: Humana Medicare	$25.60
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$41.60
Rate for Payer: Local 1199SEIU Medicare	$29.44
Rate for Payer: MVP Health Care of NY Commercial	$48.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$36.03
Rate for Payer: MVP Health Care of NY Medicare	$26.88
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$48.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$9.60
Rate for Payer: United Healthcare Commercial	$48.00
Rate for Payer: United Healthcare Medicare	$25.60
Rate for Payer: WellCare Medicare	$35.20

VITAMIN B1

Facility

$64.00

Service Code	HCPCS 84425
Hospital Charge Code	4300832
Hospital Revenue Code	301
Min. Negotiated Rate	$41.60
Max. Negotiated Rate	$41.60
Rate for Payer: Cash Price	$48.00
Rate for Payer: Galaxy Health Commercial	$41.60

VITAMIN B-12 CYANOCOBALAMIN INJ, UP TO 1000 MCG

Facility

$37.08

Service Code	HCPCS J3420
Hospital Charge Code	4400200
Hospital Revenue Code	636
Min. Negotiated Rate	$0.67
Max. Negotiated Rate	$29.66
Rate for Payer: Aetna of NY Medicare	$17.06
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$14.83
Rate for Payer: Cash Price	$27.81
Rate for Payer: Cash Price	$27.81
Rate for Payer: CDPHP Medicare	$13.72
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$0.67
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$29.66
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$29.66
Rate for Payer: EmblemHealth Medicaid	$29.66
Rate for Payer: EmblemHealth Medicare	$12.61
Rate for Payer: EmblemHealth Select Care	$0.67
Rate for Payer: Fidelis Medicare	$14.83
Rate for Payer: Galaxy Health Commercial	$24.10
Rate for Payer: Hamaspik Choice Medicare	$14.83
Rate for Payer: Humana Medicare	$14.83
Rate for Payer: Local 1199SEIU Medicare	$17.06
Rate for Payer: MVP Health Care of NY Commercial	$27.81
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$20.88
Rate for Payer: MVP Health Care of NY Medicare	$15.57
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$2.16
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$5.56
Rate for Payer: United Healthcare Commercial	$2.16
Rate for Payer: United Healthcare Medicare	$14.83
Rate for Payer: WellCare Medicare	$20.39

VITAMIN B-12 CYANOCOBALAMIN INJ, UP TO 1000 MCG

Facility

$37.08

Service Code	HCPCS J3420
Hospital Charge Code	4400200
Hospital Revenue Code	636
Min. Negotiated Rate	$0.67
Max. Negotiated Rate	$24.10
Rate for Payer: Aetna of NY Commercial	$20.39
Rate for Payer: Cash Price	$27.81
Rate for Payer: Cash Price	$27.81
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$0.67
Rate for Payer: EmblemHealth Select Care	$0.67
Rate for Payer: Galaxy Health Commercial	$24.10
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$20.39
Rate for Payer: WellCare Medicare	$20.39

VITAMIN B-12 INJECTION TO 1000 MCG

Facility

$6.18

Service Code	HCPCS J3420
Hospital Charge Code	4400803
Hospital Revenue Code	636
Min. Negotiated Rate	$0.67
Max. Negotiated Rate	$4.94
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: Cash Price	$4.64
Rate for Payer: CDPHP Medicare	$2.29
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$0.67
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	$0.67
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 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: Oxford Health Plans Freedom/Liberty/Metro	$2.16
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$0.93
Rate for Payer: United Healthcare Commercial	$2.16
Rate for Payer: United Healthcare Medicare	$2.47
Rate for Payer: WellCare Medicare	$3.40

VITAMIN B-12 INJECTION TO 1000 MCG

Facility

$6.18

Service Code	HCPCS J3420
Hospital Charge Code	4400803
Hospital Revenue Code	636
Min. Negotiated Rate	$0.67
Max. Negotiated Rate	$4.02
Rate for Payer: Aetna of NY Commercial	$3.40
Rate for Payer: Cash Price	$4.64
Rate for Payer: Cash Price	$4.64
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$0.67
Rate for Payer: EmblemHealth Select Care	$0.67
Rate for Payer: Galaxy Health Commercial	$4.02
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$3.40
Rate for Payer: WellCare Medicare	$3.40

VITAMIN B12/INTRINSIC FACTOR 1000MCG TAB

Facility

$6.18

Hospital Charge Code	4400091
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

VITAMIN B12/INTRINSIC FACTOR 1000MCG TAB

Facility

$6.18

Hospital Charge Code	4400091
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

VITAMIN B-12 LEVEL

Facility

$45.00

Service Code	HCPCS 82607
Hospital Charge Code	4300827
Hospital Revenue Code	301
Min. Negotiated Rate	$6.75
Max. Negotiated Rate	$36.00
Rate for Payer: Aetna of NY Commercial	$29.25
Rate for Payer: Aetna of NY Medicare	$20.70
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$18.00
Rate for Payer: Cash Price	$33.75
Rate for Payer: CDPHP Medicare	$16.65
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$27.00
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$36.00
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$36.00
Rate for Payer: EmblemHealth Medicaid	$36.00
Rate for Payer: EmblemHealth Medicare	$15.30
Rate for Payer: EmblemHealth Select Care	$27.00
Rate for Payer: Fidelis Medicare	$18.00
Rate for Payer: Galaxy Health Commercial	$29.25
Rate for Payer: Hamaspik Choice Medicare	$18.00
Rate for Payer: Humana Medicare	$18.00
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$29.25
Rate for Payer: Local 1199SEIU Medicare	$20.70
Rate for Payer: MVP Health Care of NY Commercial	$33.75
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$25.34
Rate for Payer: MVP Health Care of NY Medicare	$18.90
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$33.75
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$6.75
Rate for Payer: United Healthcare Commercial	$33.75
Rate for Payer: United Healthcare Medicare	$18.00
Rate for Payer: WellCare Medicare	$24.75

VITAMIN B-12 LEVEL

Facility

$45.00

Service Code	HCPCS 82607
Hospital Charge Code	4300827
Hospital Revenue Code	301
Min. Negotiated Rate	$29.25
Max. Negotiated Rate	$29.25
Rate for Payer: Cash Price	$33.75
Rate for Payer: Galaxy Health Commercial	$29.25

VITAMIN B 1 (THIAMINE) 100 MG TAB

Facility

$6.18

Service Code	NDC 77333093410
Hospital Charge Code	4409023
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

VITAMIN B 1 (THIAMINE) 100 MG TAB

Facility

$6.18

Service Code	NDC 77333093410
Hospital Charge Code	4409023
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

VITAMIN B6

Facility

$84.00

Service Code	HCPCS 84207
Hospital Charge Code	4301199
Hospital Revenue Code	301
Min. Negotiated Rate	$54.60
Max. Negotiated Rate	$54.60
Rate for Payer: Cash Price	$63.00
Rate for Payer: Galaxy Health Commercial	$54.60

VITAMIN B6

Facility

$84.00

Service Code	HCPCS 84207
Hospital Charge Code	4301199
Hospital Revenue Code	301
Min. Negotiated Rate	$12.60
Max. Negotiated Rate	$67.20
Rate for Payer: Aetna of NY Commercial	$54.60
Rate for Payer: Aetna of NY Medicare	$38.64
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$33.60
Rate for Payer: Cash Price	$63.00
Rate for Payer: CDPHP Medicare	$31.08
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$50.40
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$67.20
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$67.20
Rate for Payer: EmblemHealth Medicaid	$67.20
Rate for Payer: EmblemHealth Medicare	$28.56
Rate for Payer: EmblemHealth Select Care	$50.40
Rate for Payer: Fidelis Medicare	$33.60
Rate for Payer: Galaxy Health Commercial	$54.60
Rate for Payer: Hamaspik Choice Medicare	$33.60
Rate for Payer: Humana Medicare	$33.60
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$54.60
Rate for Payer: Local 1199SEIU Medicare	$38.64
Rate for Payer: MVP Health Care of NY Commercial	$63.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$47.29
Rate for Payer: MVP Health Care of NY Medicare	$35.28
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$63.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$12.60
Rate for Payer: United Healthcare Commercial	$63.00
Rate for Payer: United Healthcare Medicare	$33.60
Rate for Payer: WellCare Medicare	$46.20

VITAMIN B 6 (PYRIDOXINE) 100 MG TAB

Facility

$6.18

Service Code	NDC 536440901
Hospital Charge Code	4409024
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

VITAMIN B 6 (PYRIDOXINE) 100 MG TAB

Facility

$6.18

Service Code	NDC 536440901
Hospital Charge Code	4409024
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

VITAMIN D 1000U TABS 100 EA

Facility

$6.18

Service Code	NDC 48433010401
Hospital Charge Code	4400805
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

VITAMIN D 1000U TABS 100 EA

Facility

$6.18

Service Code	NDC 48433010401
Hospital Charge Code	4400805
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