Ellenville Regional Hospital

All Charges

Charge

Type

Setting

Price

BRAIN VASCULAR FLOW ONLY

Facility

$43.00

Service Code	HCPCS 78610 26
Hospital Charge Code	5210089
Hospital Revenue Code	960
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 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: 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

BRAIN VASCULAR FLOW ONLY

Facility

$43.00

Service Code	HCPCS 78610 26
Hospital Charge Code	5210089
Hospital Revenue Code	960
Min. Negotiated Rate	$27.95
Max. Negotiated Rate	$27.95
Rate for Payer: Cash Price	$32.25
Rate for Payer: Galaxy Health Commercial	$27.95

Brevibloc 2,500 MG/250 ML BAG 2500 mcg, 250 mL

Facility

$2.16

Service Code	HCPCS J1805
Hospital Charge Code	4401951
Hospital Revenue Code	636
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$1.40
Rate for Payer: Aetna of NY Commercial	$1.19
Rate for Payer: Cash Price	$1.62
Rate for Payer: Cash Price	$1.62
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$0.24
Rate for Payer: EmblemHealth Select Care	$0.24
Rate for Payer: Galaxy Health Commercial	$1.40
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$1.19
Rate for Payer: WellCare Medicare	$1.19

Brevibloc 2,500 MG/250 ML BAG 2500 mcg, 250 mL

Facility

$2.16

Service Code	HCPCS J1805
Hospital Charge Code	4401951
Hospital Revenue Code	636
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$1.73
Rate for Payer: Aetna of NY Medicare	$0.99
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$0.86
Rate for Payer: Cash Price	$1.62
Rate for Payer: Cash Price	$1.62
Rate for Payer: CDPHP Medicare	$0.80
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$0.24
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$1.73
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$1.73
Rate for Payer: EmblemHealth Medicaid	$1.73
Rate for Payer: EmblemHealth Medicare	$0.73
Rate for Payer: EmblemHealth Select Care	$0.24
Rate for Payer: Fidelis Medicare	$0.86
Rate for Payer: Galaxy Health Commercial	$1.40
Rate for Payer: Hamaspik Choice Medicare	$0.86
Rate for Payer: Humana Medicare	$0.86
Rate for Payer: Local 1199SEIU Medicare	$0.99
Rate for Payer: MVP Health Care of NY Commercial	$1.62
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$1.22
Rate for Payer: MVP Health Care of NY Medicare	$0.91
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$0.41
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$0.32
Rate for Payer: United Healthcare Commercial	$0.41
Rate for Payer: United Healthcare Medicare	$0.86
Rate for Payer: WellCare Medicare	$1.19

BREVI CATHETER 19G X 14"

Facility

$223.51

Hospital Charge Code	4473039
Hospital Revenue Code	272
Min. Negotiated Rate	$145.28
Max. Negotiated Rate	$145.28
Rate for Payer: Cash Price	$167.63
Rate for Payer: Galaxy Health Commercial	$145.28

BREVI CATHETER 19G X 14"

Facility

$223.51

Hospital Charge Code	4473039
Hospital Revenue Code	272
Min. Negotiated Rate	$33.53
Max. Negotiated Rate	$178.81
Rate for Payer: Aetna of NY Commercial	$156.46
Rate for Payer: Aetna of NY Medicare	$102.81
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$89.40
Rate for Payer: Cash Price	$167.63
Rate for Payer: CDPHP Medicare	$82.70
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$178.81
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$178.81
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$178.81
Rate for Payer: EmblemHealth Medicaid	$178.81
Rate for Payer: EmblemHealth Medicare	$75.99
Rate for Payer: EmblemHealth Select Care	$160.93
Rate for Payer: Fidelis Medicare	$89.40
Rate for Payer: Galaxy Health Commercial	$145.28
Rate for Payer: Hamaspik Choice Medicare	$89.40
Rate for Payer: Humana Medicare	$89.40
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$156.46
Rate for Payer: Local 1199SEIU Medicare	$102.81
Rate for Payer: MVP Health Care of NY Commercial	$167.63
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$125.84
Rate for Payer: MVP Health Care of NY Medicare	$93.87
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$33.53
Rate for Payer: United Healthcare Medicare	$89.40
Rate for Payer: WellCare Medicare	$122.93

BRIDION INJECTION (Sugammadex) 200 mg/ 2 ml

Facility

$359.07

Service Code	HCPCS C9399
Hospital Charge Code	4401281
Hospital Revenue Code	636
Min. Negotiated Rate	$197.49
Max. Negotiated Rate	$233.40
Rate for Payer: Aetna of NY Commercial	$197.49
Rate for Payer: Cash Price	$269.30
Rate for Payer: Galaxy Health Commercial	$233.40
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$197.49
Rate for Payer: WellCare Medicare	$197.49

BRIDION INJECTION (Sugammadex) 200 mg/ 2 ml

Facility

$359.07

Service Code	HCPCS C9399
Hospital Charge Code	4401281
Hospital Revenue Code	636
Min. Negotiated Rate	$53.86
Max. Negotiated Rate	$287.26
Rate for Payer: Aetna of NY Commercial	$197.49
Rate for Payer: Aetna of NY Medicare	$165.17
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$143.63
Rate for Payer: Cash Price	$269.30
Rate for Payer: CDPHP Medicare	$132.86
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$287.26
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$287.26
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$287.26
Rate for Payer: EmblemHealth Medicaid	$287.26
Rate for Payer: EmblemHealth Medicare	$122.08
Rate for Payer: EmblemHealth Select Care	$258.53
Rate for Payer: Fidelis Medicare	$143.63
Rate for Payer: Galaxy Health Commercial	$233.40
Rate for Payer: Hamaspik Choice Medicare	$143.63
Rate for Payer: Humana Medicare	$143.63
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$197.49
Rate for Payer: Local 1199SEIU Medicare	$165.17
Rate for Payer: MVP Health Care of NY Commercial	$269.30
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$202.16
Rate for Payer: MVP Health Care of NY Medicare	$150.81
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$53.86
Rate for Payer: United Healthcare Medicare	$143.63
Rate for Payer: WellCare Medicare	$197.49

Brilinta 60 MG TABLET 60 mg, 60 eaches

Facility

$26.00

Service Code	NDC 186077660
Hospital Charge Code	4401554
Hospital Revenue Code	250
Min. Negotiated Rate	$3.90
Max. Negotiated Rate	$20.80
Rate for Payer: Aetna of NY Commercial	$18.20
Rate for Payer: Aetna of NY Medicare	$11.96
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$10.40
Rate for Payer: Cash Price	$19.50
Rate for Payer: CDPHP Medicare	$9.62
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$20.80
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$20.80
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$20.80
Rate for Payer: EmblemHealth Medicaid	$20.80
Rate for Payer: EmblemHealth Medicare	$8.84
Rate for Payer: EmblemHealth Select Care	$18.72
Rate for Payer: Fidelis Medicare	$10.40
Rate for Payer: Galaxy Health Commercial	$16.90
Rate for Payer: Hamaspik Choice Medicare	$10.40
Rate for Payer: Humana Medicare	$10.40
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$18.20
Rate for Payer: Local 1199SEIU Medicare	$11.96
Rate for Payer: MVP Health Care of NY Commercial	$19.50
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$14.64
Rate for Payer: MVP Health Care of NY Medicare	$10.92
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$3.90
Rate for Payer: United Healthcare Medicare	$10.40
Rate for Payer: WellCare Medicare	$14.30

Brilinta 60 MG TABLET 60 mg, 60 eaches

Facility

$26.00

Service Code	NDC 186077660
Hospital Charge Code	4401554
Hospital Revenue Code	250
Min. Negotiated Rate	$14.30
Max. Negotiated Rate	$16.90
Rate for Payer: Cash Price	$19.50
Rate for Payer: Galaxy Health Commercial	$16.90
Rate for Payer: WellCare Medicare	$14.30

Brilinta 90 MG TABLET 90 mg, 60 eaches

Facility

$21.00

Service Code	NDC 186077760
Hospital Charge Code	44001317
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

Brilinta 90 MG TABLET 90 mg, 60 eaches

Facility

$21.00

Service Code	NDC 186077760
Hospital Charge Code	44001317
Hospital Revenue Code	250
Min. Negotiated Rate	$3.15
Max. Negotiated Rate	$16.80
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) Medicare	$8.40
Rate for Payer: Cash Price	$15.75
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	$8.40
Rate for Payer: Galaxy Health Commercial	$13.65
Rate for Payer: Hamaspik Choice Medicare	$8.40
Rate for Payer: Humana Medicare	$8.40
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	$8.82
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$3.15
Rate for Payer: United Healthcare Medicare	$8.40
Rate for Payer: WellCare Medicare	$11.55

BRIMONIDINE 0.2 % EYE DROPS

Facility

$97.95

Service Code	NDC 24208041105
Hospital Charge Code	4409101
Hospital Revenue Code	250
Min. Negotiated Rate	$14.69
Max. Negotiated Rate	$78.36
Rate for Payer: Aetna of NY Commercial	$68.56
Rate for Payer: Aetna of NY Medicare	$45.06
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$39.18
Rate for Payer: Cash Price	$73.46
Rate for Payer: CDPHP Medicare	$36.24
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$78.36
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$78.36
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$78.36
Rate for Payer: EmblemHealth Medicaid	$78.36
Rate for Payer: EmblemHealth Medicare	$33.30
Rate for Payer: EmblemHealth Select Care	$70.52
Rate for Payer: Fidelis Medicare	$39.18
Rate for Payer: Galaxy Health Commercial	$63.67
Rate for Payer: Hamaspik Choice Medicare	$39.18
Rate for Payer: Humana Medicare	$39.18
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$68.56
Rate for Payer: Local 1199SEIU Medicare	$45.06
Rate for Payer: MVP Health Care of NY Commercial	$73.46
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$55.15
Rate for Payer: MVP Health Care of NY Medicare	$41.14
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$14.69
Rate for Payer: United Healthcare Medicare	$39.18
Rate for Payer: WellCare Medicare	$53.87

BRIMONIDINE 0.2 % EYE DROPS

Facility

$97.95

Service Code	NDC 24208041105
Hospital Charge Code	4409101
Hospital Revenue Code	250
Min. Negotiated Rate	$53.87
Max. Negotiated Rate	$63.67
Rate for Payer: Cash Price	$73.46
Rate for Payer: Galaxy Health Commercial	$63.67
Rate for Payer: WellCare Medicare	$53.87

BS 30CM SPLITTER 2X8 KIT

Facility

$6,662.04

Service Code	HCPCS C1883
Hospital Charge Code	4472219
Hospital Revenue Code	278
Min. Negotiated Rate	$999.31
Max. Negotiated Rate	$5,329.63
Rate for Payer: Aetna of NY Commercial	$4,663.43
Rate for Payer: Aetna of NY Medicare	$3,064.54
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$2,664.82
Rate for Payer: Cash Price	$4,996.53
Rate for Payer: CDPHP Medicare	$2,464.95
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$3,331.02
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$5,329.63
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$5,329.63
Rate for Payer: EmblemHealth Medicaid	$5,329.63
Rate for Payer: EmblemHealth Medicare	$2,265.09
Rate for Payer: EmblemHealth Select Care	$3,331.02
Rate for Payer: Fidelis Medicare	$2,664.82
Rate for Payer: Galaxy Health Commercial	$4,330.33
Rate for Payer: Hamaspik Choice Medicare	$2,664.82
Rate for Payer: Humana Medicare	$2,664.82
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$4,663.43
Rate for Payer: Local 1199SEIU Medicare	$3,064.54
Rate for Payer: MVP Health Care of NY Commercial	$4,330.33
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$4,330.33
Rate for Payer: MVP Health Care of NY Medicare	$2,798.06
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$999.31
Rate for Payer: United Healthcare Medicare	$2,664.82
Rate for Payer: WellCare Medicare	$3,664.12

BS 30CM SPLITTER 2X8 KIT

Facility

$6,662.04

Service Code	HCPCS C1883
Hospital Charge Code	4472219
Hospital Revenue Code	278
Min. Negotiated Rate	$2,997.92
Max. Negotiated Rate	$4,663.43
Rate for Payer: Aetna of NY Commercial	$4,663.43
Rate for Payer: Cash Price	$4,996.53
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$3,331.02
Rate for Payer: EmblemHealth Select Care	$3,331.02
Rate for Payer: Galaxy Health Commercial	$4,330.33
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$4,663.43
Rate for Payer: Multiplan Commercial	$2,997.92
Rate for Payer: MVP Health Care of NY Commercial	$4,330.33
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$4,330.33
Rate for Payer: WellCare Medicare	$3,664.12

BUDESONIDE NEB SOL 0.25

Facility

$29.10

Service Code	HCPCS J7626
Hospital Charge Code	4401244
Hospital Revenue Code	636
Min. Negotiated Rate	$1.09
Max. Negotiated Rate	$18.91
Rate for Payer: Aetna of NY Commercial	$16.00
Rate for Payer: Cash Price	$21.83
Rate for Payer: Cash Price	$21.83
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$1.09
Rate for Payer: EmblemHealth Select Care	$1.09
Rate for Payer: Galaxy Health Commercial	$18.91
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$16.00
Rate for Payer: WellCare Medicare	$16.00

BUDESONIDE NEB SOL 0.25

Facility

$29.10

Service Code	HCPCS J7626
Hospital Charge Code	4401244
Hospital Revenue Code	636
Min. Negotiated Rate	$1.09
Max. Negotiated Rate	$23.28
Rate for Payer: Aetna of NY Medicare	$13.39
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$11.64
Rate for Payer: Cash Price	$21.83
Rate for Payer: Cash Price	$21.83
Rate for Payer: CDPHP Medicare	$10.77
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$1.09
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$23.28
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$23.28
Rate for Payer: EmblemHealth Medicaid	$23.28
Rate for Payer: EmblemHealth Medicare	$9.89
Rate for Payer: EmblemHealth Select Care	$1.09
Rate for Payer: Fidelis Medicare	$11.64
Rate for Payer: Galaxy Health Commercial	$18.91
Rate for Payer: Hamaspik Choice Medicare	$11.64
Rate for Payer: Humana Medicare	$11.64
Rate for Payer: Local 1199SEIU Medicare	$13.39
Rate for Payer: MVP Health Care of NY Commercial	$21.82
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$16.38
Rate for Payer: MVP Health Care of NY Medicare	$12.22
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$1.45
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$4.37
Rate for Payer: United Healthcare Commercial	$1.45
Rate for Payer: United Healthcare Medicare	$11.64
Rate for Payer: WellCare Medicare	$16.00

BUDESONIDE NEB SOL 0.5

Facility

$33.50

Service Code	HCPCS J7626
Hospital Charge Code	4401245
Hospital Revenue Code	636
Min. Negotiated Rate	$1.09
Max. Negotiated Rate	$21.77
Rate for Payer: Aetna of NY Commercial	$18.43
Rate for Payer: Cash Price	$25.12
Rate for Payer: Cash Price	$25.12
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$1.09
Rate for Payer: EmblemHealth Select Care	$1.09
Rate for Payer: Galaxy Health Commercial	$21.77
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$18.43
Rate for Payer: WellCare Medicare	$18.43

BUDESONIDE NEB SOL 0.5

Facility

$33.50

Service Code	HCPCS J7626
Hospital Charge Code	4401245
Hospital Revenue Code	636
Min. Negotiated Rate	$1.09
Max. Negotiated Rate	$26.80
Rate for Payer: Aetna of NY Medicare	$15.41
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$13.40
Rate for Payer: Cash Price	$25.12
Rate for Payer: Cash Price	$25.12
Rate for Payer: CDPHP Medicare	$12.39
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$1.09
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$26.80
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$26.80
Rate for Payer: EmblemHealth Medicaid	$26.80
Rate for Payer: EmblemHealth Medicare	$11.39
Rate for Payer: EmblemHealth Select Care	$1.09
Rate for Payer: Fidelis Medicare	$13.40
Rate for Payer: Galaxy Health Commercial	$21.77
Rate for Payer: Hamaspik Choice Medicare	$13.40
Rate for Payer: Humana Medicare	$13.40
Rate for Payer: Local 1199SEIU Medicare	$15.41
Rate for Payer: MVP Health Care of NY Commercial	$25.12
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$18.86
Rate for Payer: MVP Health Care of NY Medicare	$14.07
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$1.45
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$5.03
Rate for Payer: United Healthcare Commercial	$1.45
Rate for Payer: United Healthcare Medicare	$13.40
Rate for Payer: WellCare Medicare	$18.43

BUMETANIDE 0.25MG/ML SDV 10X2ML

Facility

$7.73

Service Code	HCPCS J3490
Hospital Charge Code	4400114
Hospital Revenue Code	636
Min. Negotiated Rate	$4.25
Max. Negotiated Rate	$5.02
Rate for Payer: Aetna of NY Commercial	$4.25
Rate for Payer: Cash Price	$5.80
Rate for Payer: Galaxy Health Commercial	$5.02
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$4.25
Rate for Payer: WellCare Medicare	$4.25

BUMETANIDE 0.25MG/ML SDV 10X2ML

Facility

$7.73

Service Code	HCPCS J3490
Hospital Charge Code	4400114
Hospital Revenue Code	636
Min. Negotiated Rate	$1.16
Max. Negotiated Rate	$6.18
Rate for Payer: Aetna of NY Medicare	$3.56
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$3.09
Rate for Payer: Cash Price	$5.80
Rate for Payer: CDPHP Medicare	$2.86
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$6.18
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$6.18
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$6.18
Rate for Payer: EmblemHealth Medicaid	$6.18
Rate for Payer: EmblemHealth Medicare	$2.63
Rate for Payer: EmblemHealth Select Care	$5.57
Rate for Payer: Fidelis Medicare	$3.09
Rate for Payer: Galaxy Health Commercial	$5.02
Rate for Payer: Hamaspik Choice Medicare	$3.09
Rate for Payer: Humana Medicare	$3.09
Rate for Payer: Local 1199SEIU Medicare	$3.56
Rate for Payer: MVP Health Care of NY Commercial	$5.80
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$4.35
Rate for Payer: MVP Health Care of NY Medicare	$3.25
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$1.16
Rate for Payer: United Healthcare Medicare	$3.09
Rate for Payer: WellCare Medicare	$4.25

BUMETANIDE 1MG TABS 10X10EA

Facility

$6.18

Service Code	NDC 93423301
Hospital Charge Code	4400115
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

BUMETANIDE 1MG TABS 10X10EA

Facility

$6.18

Service Code	NDC 93423301
Hospital Charge Code	4400115
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

BUPIVACAINE-DEXTR 0.75% AMP 1 ea, 2 mL

Facility

$6.00

Service Code	NDC 409361301
Hospital Charge Code	4401309
Hospital Revenue Code	250
Min. Negotiated Rate	$3.30
Max. Negotiated Rate	$3.90
Rate for Payer: Cash Price	$4.50
Rate for Payer: Galaxy Health Commercial	$3.90
Rate for Payer: WellCare Medicare	$3.30

Know your out-of-pocket cost for care.

All Charges