Ellenville Regional Hospital

All Charges

Charge

Type

Setting

Price

CHLAMYDIA T DIR NA PROBE

Facility

$68.00

Service Code	HCPCS 87490
Hospital Charge Code	4301440
Hospital Revenue Code	306
Min. Negotiated Rate	$44.20
Max. Negotiated Rate	$44.20
Rate for Payer: Cash Price	$51.00
Rate for Payer: Galaxy Health Commercial	$44.20

CHLORAPREP 10.5ML

Facility

$14.42

Hospital Charge Code	4471236
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

CHLORAPREP 10.5ML

Facility

$14.42

Hospital Charge Code	4471236
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

CHLORASEPTIC SORE THROAT LOZNG 6 mg, 18 eaches

Facility

$6.00

Service Code	NDC 78112001266
Hospital Charge Code	4401932
Hospital Revenue Code	250
Min. Negotiated Rate	$0.90
Max. Negotiated Rate	$4.80
Rate for Payer: Aetna of NY Commercial	$4.20
Rate for Payer: Aetna of NY Medicare	$2.76
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$2.40
Rate for Payer: Cash Price	$4.50
Rate for Payer: CDPHP Medicare	$2.22
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$4.80
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$4.80
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$4.80
Rate for Payer: EmblemHealth Medicaid	$4.80
Rate for Payer: EmblemHealth Medicare	$2.04
Rate for Payer: EmblemHealth Select Care	$4.32
Rate for Payer: Fidelis Medicare	$2.40
Rate for Payer: Galaxy Health Commercial	$3.90
Rate for Payer: Hamaspik Choice Medicare	$2.40
Rate for Payer: Humana Medicare	$2.40
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$4.20
Rate for Payer: Local 1199SEIU Medicare	$2.76
Rate for Payer: MVP Health Care of NY Commercial	$4.50
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$3.38
Rate for Payer: MVP Health Care of NY Medicare	$2.52
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$0.90
Rate for Payer: United Healthcare Medicare	$2.40
Rate for Payer: WellCare Medicare	$3.30

CHLORASEPTIC SORE THROAT LOZNG 6 mg, 18 eaches

Facility

$6.00

Service Code	NDC 78112001266
Hospital Charge Code	4401932
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

CHLORDIAZEPOXIDE HCL 25MG CAPS 100 EA

Facility

$6.18

Service Code	NDC 51079014120
Hospital Charge Code	4400157
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

CHLORDIAZEPOXIDE HCL 25MG CAPS 100 EA

Facility

$6.18

Service Code	NDC 51079014120
Hospital Charge Code	4400157
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

CHLORDIAZEPOXIDE HCL 5MG CAPS 100 EA

Facility

$6.18

Service Code	NDC 51079037420
Hospital Charge Code	4400158
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

CHLORDIAZEPOXIDE HCL 5MG CAPS 100 EA

Facility

$6.18

Service Code	NDC 51079037420
Hospital Charge Code	4400158
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

CHLORHEXIDINE .12 % ORAL RINSE

Facility

$6.18

Service Code	NDC 116200116
Hospital Charge Code	4408973
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

CHLORHEXIDINE .12 % ORAL RINSE

Facility

$6.18

Service Code	NDC 116200116
Hospital Charge Code	4408973
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

CHLORIDE SERUM

Facility

$14.00

Service Code	HCPCS 82435
Hospital Charge Code	4300175
Hospital Revenue Code	301
Min. Negotiated Rate	$2.10
Max. Negotiated Rate	$11.20
Rate for Payer: Aetna of NY Commercial	$9.10
Rate for Payer: Aetna of NY Medicare	$6.44
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$5.60
Rate for Payer: Cash Price	$10.50
Rate for Payer: CDPHP Medicare	$5.18
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$8.40
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$11.20
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$11.20
Rate for Payer: EmblemHealth Medicaid	$11.20
Rate for Payer: EmblemHealth Medicare	$4.76
Rate for Payer: EmblemHealth Select Care	$8.40
Rate for Payer: Fidelis Medicare	$5.60
Rate for Payer: Galaxy Health Commercial	$9.10
Rate for Payer: Hamaspik Choice Medicare	$5.60
Rate for Payer: Humana Medicare	$5.60
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$9.10
Rate for Payer: Local 1199SEIU Medicare	$6.44
Rate for Payer: MVP Health Care of NY Commercial	$10.50
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$7.88
Rate for Payer: MVP Health Care of NY Medicare	$5.88
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$10.50
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$2.10
Rate for Payer: United Healthcare Commercial	$10.50
Rate for Payer: United Healthcare Medicare	$5.60
Rate for Payer: WellCare Medicare	$7.70

CHLORIDE SERUM

Facility

$14.00

Service Code	HCPCS 82435
Hospital Charge Code	4300175
Hospital Revenue Code	301
Min. Negotiated Rate	$9.10
Max. Negotiated Rate	$9.10
Rate for Payer: Cash Price	$10.50
Rate for Payer: Galaxy Health Commercial	$9.10

chlorproMAZINE 25 MG TABLET 25 mg, 50 eaches

Facility

$23.00

Service Code	NDC 50268016315
Hospital Charge Code	4401536
Hospital Revenue Code	250
Min. Negotiated Rate	$3.45
Max. Negotiated Rate	$18.40
Rate for Payer: Aetna of NY Commercial	$16.10
Rate for Payer: Aetna of NY Medicare	$10.58
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$9.20
Rate for Payer: Cash Price	$17.25
Rate for Payer: CDPHP Medicare	$8.51
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$18.40
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$18.40
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$18.40
Rate for Payer: EmblemHealth Medicaid	$18.40
Rate for Payer: EmblemHealth Medicare	$7.82
Rate for Payer: EmblemHealth Select Care	$16.56
Rate for Payer: Fidelis Medicare	$9.20
Rate for Payer: Galaxy Health Commercial	$14.95
Rate for Payer: Hamaspik Choice Medicare	$9.20
Rate for Payer: Humana Medicare	$9.20
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$16.10
Rate for Payer: Local 1199SEIU Medicare	$10.58
Rate for Payer: MVP Health Care of NY Commercial	$17.25
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$12.95
Rate for Payer: MVP Health Care of NY Medicare	$9.66
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$3.45
Rate for Payer: United Healthcare Medicare	$9.20
Rate for Payer: WellCare Medicare	$12.65

chlorproMAZINE 25 MG TABLET 25 mg, 50 eaches

Facility

$23.00

Service Code	NDC 50268016315
Hospital Charge Code	4401536
Hospital Revenue Code	250
Min. Negotiated Rate	$12.65
Max. Negotiated Rate	$14.95
Rate for Payer: Cash Price	$17.25
Rate for Payer: Galaxy Health Commercial	$14.95
Rate for Payer: WellCare Medicare	$12.65

CHLORTHALIDONE 25 MG TABLET 25 mg, 30 eaches

Facility

$8.00

Service Code	NDC 60687031725
Hospital Charge Code	4401913
Hospital Revenue Code	250
Min. Negotiated Rate	$1.20
Max. Negotiated Rate	$6.40
Rate for Payer: Aetna of NY Commercial	$5.60
Rate for Payer: Aetna of NY Medicare	$3.68
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$3.20
Rate for Payer: Cash Price	$6.00
Rate for Payer: CDPHP Medicare	$2.96
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$6.40
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$6.40
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$6.40
Rate for Payer: EmblemHealth Medicaid	$6.40
Rate for Payer: EmblemHealth Medicare	$2.72
Rate for Payer: EmblemHealth Select Care	$5.76
Rate for Payer: Fidelis Medicare	$3.20
Rate for Payer: Galaxy Health Commercial	$5.20
Rate for Payer: Hamaspik Choice Medicare	$3.20
Rate for Payer: Humana Medicare	$3.20
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$5.60
Rate for Payer: Local 1199SEIU Medicare	$3.68
Rate for Payer: MVP Health Care of NY Commercial	$6.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$4.50
Rate for Payer: MVP Health Care of NY Medicare	$3.36
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$1.20
Rate for Payer: United Healthcare Medicare	$3.20
Rate for Payer: WellCare Medicare	$4.40

CHLORTHALIDONE 25 MG TABLET 25 mg, 30 eaches

Facility

$8.00

Service Code	NDC 60687031725
Hospital Charge Code	4401913
Hospital Revenue Code	250
Min. Negotiated Rate	$4.40
Max. Negotiated Rate	$5.20
Rate for Payer: Cash Price	$6.00
Rate for Payer: Galaxy Health Commercial	$5.20
Rate for Payer: WellCare Medicare	$4.40

CHOLESTYRAMINE/SUCROSE 4GM PCKT 60 EA

Facility

$10.30

Service Code	NDC 49884046565
Hospital Charge Code	4400159
Hospital Revenue Code	250
Min. Negotiated Rate	$5.67
Max. Negotiated Rate	$6.70
Rate for Payer: Cash Price	$7.72
Rate for Payer: Galaxy Health Commercial	$6.70
Rate for Payer: WellCare Medicare	$5.67

CHOLESTYRAMINE/SUCROSE 4GM PCKT 60 EA

Facility

$10.30

Service Code	NDC 49884046565
Hospital Charge Code	4400159
Hospital Revenue Code	250
Min. Negotiated Rate	$1.54
Max. Negotiated Rate	$8.24
Rate for Payer: Aetna of NY Commercial	$7.21
Rate for Payer: Aetna of NY Medicare	$4.74
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$4.12
Rate for Payer: Cash Price	$7.72
Rate for Payer: CDPHP Medicare	$3.81
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$8.24
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$8.24
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$8.24
Rate for Payer: EmblemHealth Medicaid	$8.24
Rate for Payer: EmblemHealth Medicare	$3.50
Rate for Payer: EmblemHealth Select Care	$7.42
Rate for Payer: Fidelis Medicare	$4.12
Rate for Payer: Galaxy Health Commercial	$6.70
Rate for Payer: Hamaspik Choice Medicare	$4.12
Rate for Payer: Humana Medicare	$4.12
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$7.21
Rate for Payer: Local 1199SEIU Medicare	$4.74
Rate for Payer: MVP Health Care of NY Commercial	$7.72
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$5.80
Rate for Payer: MVP Health Care of NY Medicare	$4.33
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$1.54
Rate for Payer: United Healthcare Medicare	$4.12
Rate for Payer: WellCare Medicare	$5.67

CHROMIC GUT 4-0

Facility

$20.60

Hospital Charge Code	4479302
Hospital Revenue Code	270
Min. Negotiated Rate	$3.09
Max. Negotiated Rate	$16.48
Rate for Payer: Aetna of NY Commercial	$14.42
Rate for Payer: Aetna of NY Medicare	$9.48
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$8.24
Rate for Payer: Cash Price	$15.45
Rate for Payer: CDPHP Medicare	$7.62
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$16.48
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$16.48
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$16.48
Rate for Payer: EmblemHealth Medicaid	$16.48
Rate for Payer: EmblemHealth Medicare	$7.00
Rate for Payer: EmblemHealth Select Care	$14.83
Rate for Payer: Fidelis Medicare	$8.24
Rate for Payer: Galaxy Health Commercial	$13.39
Rate for Payer: Hamaspik Choice Medicare	$8.24
Rate for Payer: Humana Medicare	$8.24
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$14.42
Rate for Payer: Local 1199SEIU Medicare	$9.48
Rate for Payer: MVP Health Care of NY Commercial	$15.45
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$11.60
Rate for Payer: MVP Health Care of NY Medicare	$8.65
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$3.09
Rate for Payer: United Healthcare Medicare	$8.24
Rate for Payer: WellCare Medicare	$11.33

CHROMIC GUT 4-0

Facility

$20.60

Hospital Charge Code	4479302
Hospital Revenue Code	270
Min. Negotiated Rate	$13.39
Max. Negotiated Rate	$13.39
Rate for Payer: Cash Price	$15.45
Rate for Payer: Galaxy Health Commercial	$13.39

CHROMIC GUT 5-0

Facility

$35.02

Hospital Charge Code	4479304
Hospital Revenue Code	270
Min. Negotiated Rate	$5.25
Max. Negotiated Rate	$28.02
Rate for Payer: Aetna of NY Commercial	$24.51
Rate for Payer: Aetna of NY Medicare	$16.11
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$14.01
Rate for Payer: Cash Price	$26.26
Rate for Payer: CDPHP Medicare	$12.96
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$28.02
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$28.02
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$28.02
Rate for Payer: EmblemHealth Medicaid	$28.02
Rate for Payer: EmblemHealth Medicare	$11.91
Rate for Payer: EmblemHealth Select Care	$25.21
Rate for Payer: Fidelis Medicare	$14.01
Rate for Payer: Galaxy Health Commercial	$22.76
Rate for Payer: Hamaspik Choice Medicare	$14.01
Rate for Payer: Humana Medicare	$14.01
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$24.51
Rate for Payer: Local 1199SEIU Medicare	$16.11
Rate for Payer: MVP Health Care of NY Commercial	$26.27
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$19.72
Rate for Payer: MVP Health Care of NY Medicare	$14.71
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$5.25
Rate for Payer: United Healthcare Medicare	$14.01
Rate for Payer: WellCare Medicare	$19.26

CHROMIC GUT 5-0

Facility

$35.02

Hospital Charge Code	4479304
Hospital Revenue Code	270
Min. Negotiated Rate	$22.76
Max. Negotiated Rate	$22.76
Rate for Payer: Cash Price	$26.26
Rate for Payer: Galaxy Health Commercial	$22.76

CICLOPIROX 0.77% CREAM 1 ea, 30 g

Facility

$170.00

Service Code	NDC 45802013811
Hospital Charge Code	4401449
Hospital Revenue Code	250
Min. Negotiated Rate	$93.50
Max. Negotiated Rate	$110.50
Rate for Payer: Cash Price	$127.50
Rate for Payer: Galaxy Health Commercial	$110.50
Rate for Payer: WellCare Medicare	$93.50

CICLOPIROX 0.77% CREAM 1 ea, 30 g

Facility

$170.00

Service Code	NDC 45802013811
Hospital Charge Code	4401449
Hospital Revenue Code	250
Min. Negotiated Rate	$25.50
Max. Negotiated Rate	$136.00
Rate for Payer: Aetna of NY Commercial	$119.00
Rate for Payer: Aetna of NY Medicare	$78.20
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$68.00
Rate for Payer: Cash Price	$127.50
Rate for Payer: CDPHP Medicare	$62.90
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$136.00
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$136.00
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$136.00
Rate for Payer: EmblemHealth Medicaid	$136.00
Rate for Payer: EmblemHealth Medicare	$57.80
Rate for Payer: EmblemHealth Select Care	$122.40
Rate for Payer: Fidelis Medicare	$68.00
Rate for Payer: Galaxy Health Commercial	$110.50
Rate for Payer: Hamaspik Choice Medicare	$68.00
Rate for Payer: Humana Medicare	$68.00
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$119.00
Rate for Payer: Local 1199SEIU Medicare	$78.20
Rate for Payer: MVP Health Care of NY Commercial	$127.50
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$95.71
Rate for Payer: MVP Health Care of NY Medicare	$71.40
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$25.50
Rate for Payer: United Healthcare Medicare	$68.00
Rate for Payer: WellCare Medicare	$93.50

Know your out-of-pocket cost for care.

All Charges