Ellenville Regional Hospital

All Charges

Charge

Type

Setting

Price

CILASTATIN SODIUM; IMIPENEM, PER 250 MG

Facility

$46.35

Service Code	HCPCS J0743
Hospital Charge Code	4400650
Hospital Revenue Code	636
Min. Negotiated Rate	$6.32
Max. Negotiated Rate	$30.13
Rate for Payer: Aetna of NY Commercial	$25.49
Rate for Payer: Cash Price	$34.76
Rate for Payer: Cash Price	$34.76
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$6.32
Rate for Payer: EmblemHealth Select Care	$6.32
Rate for Payer: Galaxy Health Commercial	$30.13
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$25.49
Rate for Payer: WellCare Medicare	$25.49

CILASTATIN SODIUM; IMIPENEM, PER 250 MG

Facility

$46.35

Service Code	HCPCS J0743
Hospital Charge Code	4400650
Hospital Revenue Code	636
Min. Negotiated Rate	$6.32
Max. Negotiated Rate	$37.08
Rate for Payer: Aetna of NY Medicare	$21.32
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$18.54
Rate for Payer: Cash Price	$34.76
Rate for Payer: Cash Price	$34.76
Rate for Payer: CDPHP Medicare	$17.15
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$6.32
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$37.08
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$37.08
Rate for Payer: EmblemHealth Medicaid	$37.08
Rate for Payer: EmblemHealth Medicare	$15.76
Rate for Payer: EmblemHealth Select Care	$6.32
Rate for Payer: Fidelis Medicare	$18.54
Rate for Payer: Galaxy Health Commercial	$30.13
Rate for Payer: Hamaspik Choice Medicare	$18.54
Rate for Payer: Humana Medicare	$18.54
Rate for Payer: Local 1199SEIU Medicare	$21.32
Rate for Payer: MVP Health Care of NY Commercial	$34.76
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$26.10
Rate for Payer: MVP Health Care of NY Medicare	$19.47
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$11.80
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$6.95
Rate for Payer: United Healthcare Commercial	$11.80
Rate for Payer: United Healthcare Medicare	$18.54
Rate for Payer: WellCare Medicare	$25.49

CILASTATIN SODIUM; IMIPENEM, PER 250 MG

Facility

$75.00

Service Code	HCPCS J0743
Hospital Charge Code	4400651
Hospital Revenue Code	636
Min. Negotiated Rate	$6.32
Max. Negotiated Rate	$48.75
Rate for Payer: Aetna of NY Commercial	$41.25
Rate for Payer: Cash Price	$56.25
Rate for Payer: Cash Price	$56.25
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$6.32
Rate for Payer: EmblemHealth Select Care	$6.32
Rate for Payer: Galaxy Health Commercial	$48.75
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$41.25
Rate for Payer: WellCare Medicare	$41.25

CILASTATIN SODIUM; IMIPENEM, PER 250 MG

Facility

$75.00

Service Code	HCPCS J0743
Hospital Charge Code	4400651
Hospital Revenue Code	636
Min. Negotiated Rate	$6.32
Max. Negotiated Rate	$60.00
Rate for Payer: Aetna of NY Medicare	$34.50
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$30.00
Rate for Payer: Cash Price	$56.25
Rate for Payer: Cash Price	$56.25
Rate for Payer: CDPHP Medicare	$27.75
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$6.32
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$60.00
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$60.00
Rate for Payer: EmblemHealth Medicaid	$60.00
Rate for Payer: EmblemHealth Medicare	$25.50
Rate for Payer: EmblemHealth Select Care	$6.32
Rate for Payer: Fidelis Medicare	$30.00
Rate for Payer: Galaxy Health Commercial	$48.75
Rate for Payer: Hamaspik Choice Medicare	$30.00
Rate for Payer: Humana Medicare	$30.00
Rate for Payer: Local 1199SEIU Medicare	$34.50
Rate for Payer: MVP Health Care of NY Commercial	$56.25
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$42.23
Rate for Payer: MVP Health Care of NY Medicare	$31.50
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$11.80
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$11.25
Rate for Payer: United Healthcare Commercial	$11.80
Rate for Payer: United Healthcare Medicare	$30.00
Rate for Payer: WellCare Medicare	$41.25

CINACALCET HCL 30MG TABS 30 EA

Facility

$85.49

Service Code	NDC 55513007330
Hospital Charge Code	4400691
Hospital Revenue Code	250
Min. Negotiated Rate	$47.02
Max. Negotiated Rate	$55.57
Rate for Payer: Cash Price	$64.12
Rate for Payer: Galaxy Health Commercial	$55.57
Rate for Payer: WellCare Medicare	$47.02

CINACALCET HCL 30MG TABS 30 EA

Facility

$85.49

Service Code	NDC 55513007330
Hospital Charge Code	4400691
Hospital Revenue Code	250
Min. Negotiated Rate	$12.82
Max. Negotiated Rate	$68.39
Rate for Payer: Aetna of NY Commercial	$59.84
Rate for Payer: Aetna of NY Medicare	$39.33
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$34.20
Rate for Payer: Cash Price	$64.12
Rate for Payer: CDPHP Medicare	$31.63
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$68.39
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$68.39
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$68.39
Rate for Payer: EmblemHealth Medicaid	$68.39
Rate for Payer: EmblemHealth Medicare	$29.07
Rate for Payer: EmblemHealth Select Care	$61.55
Rate for Payer: Fidelis Medicare	$34.20
Rate for Payer: Galaxy Health Commercial	$55.57
Rate for Payer: Hamaspik Choice Medicare	$34.20
Rate for Payer: Humana Medicare	$34.20
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$59.84
Rate for Payer: Local 1199SEIU Medicare	$39.33
Rate for Payer: MVP Health Care of NY Commercial	$64.12
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$48.13
Rate for Payer: MVP Health Care of NY Medicare	$35.91
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$12.82
Rate for Payer: United Healthcare Medicare	$34.20
Rate for Payer: WellCare Medicare	$47.02

CIPROFLOXACIN HCL 250MG TABS 10X10EA

Facility

$16.74

Service Code	NDC 63739070010
Hospital Charge Code	4400161
Hospital Revenue Code	250
Min. Negotiated Rate	$9.21
Max. Negotiated Rate	$10.88
Rate for Payer: Cash Price	$12.56
Rate for Payer: Galaxy Health Commercial	$10.88
Rate for Payer: WellCare Medicare	$9.21

CIPROFLOXACIN HCL 250MG TABS 10X10EA

Facility

$16.74

Service Code	NDC 63739070010
Hospital Charge Code	4400161
Hospital Revenue Code	250
Min. Negotiated Rate	$2.51
Max. Negotiated Rate	$13.39
Rate for Payer: Aetna of NY Commercial	$11.72
Rate for Payer: Aetna of NY Medicare	$7.70
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$6.70
Rate for Payer: Cash Price	$12.56
Rate for Payer: CDPHP Medicare	$6.19
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$13.39
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$13.39
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$13.39
Rate for Payer: EmblemHealth Medicaid	$13.39
Rate for Payer: EmblemHealth Medicare	$5.69
Rate for Payer: EmblemHealth Select Care	$12.05
Rate for Payer: Fidelis Medicare	$6.70
Rate for Payer: Galaxy Health Commercial	$10.88
Rate for Payer: Hamaspik Choice Medicare	$6.70
Rate for Payer: Humana Medicare	$6.70
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$11.72
Rate for Payer: Local 1199SEIU Medicare	$7.70
Rate for Payer: MVP Health Care of NY Commercial	$12.55
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$9.42
Rate for Payer: MVP Health Care of NY Medicare	$7.03
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$2.51
Rate for Payer: United Healthcare Medicare	$6.70
Rate for Payer: WellCare Medicare	$9.21

CIPROFLOXACIN HCL 500MG TABS 10X10EA

Facility

$15.71

Service Code	NDC 68084007011
Hospital Charge Code	4400160
Hospital Revenue Code	250
Min. Negotiated Rate	$2.36
Max. Negotiated Rate	$12.57
Rate for Payer: Aetna of NY Commercial	$11.00
Rate for Payer: Aetna of NY Medicare	$7.23
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$6.28
Rate for Payer: Cash Price	$11.78
Rate for Payer: CDPHP Medicare	$5.81
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$12.57
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$12.57
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$12.57
Rate for Payer: EmblemHealth Medicaid	$12.57
Rate for Payer: EmblemHealth Medicare	$5.34
Rate for Payer: EmblemHealth Select Care	$11.31
Rate for Payer: Fidelis Medicare	$6.28
Rate for Payer: Galaxy Health Commercial	$10.21
Rate for Payer: Hamaspik Choice Medicare	$6.28
Rate for Payer: Humana Medicare	$6.28
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$11.00
Rate for Payer: Local 1199SEIU Medicare	$7.23
Rate for Payer: MVP Health Care of NY Commercial	$11.78
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$8.84
Rate for Payer: MVP Health Care of NY Medicare	$6.60
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$2.36
Rate for Payer: United Healthcare Medicare	$6.28
Rate for Payer: WellCare Medicare	$8.64

CIPROFLOXACIN HCL 500MG TABS 10X10EA

Facility

$15.71

Service Code	NDC 68084007011
Hospital Charge Code	4400160
Hospital Revenue Code	250
Min. Negotiated Rate	$8.64
Max. Negotiated Rate	$10.21
Rate for Payer: Cash Price	$11.78
Rate for Payer: Galaxy Health Commercial	$10.21
Rate for Payer: WellCare Medicare	$8.64

CIPROFLOXACIN IV INJ 200 MG

Facility

$10.82

Service Code	HCPCS J0744
Hospital Charge Code	4450002
Hospital Revenue Code	636
Min. Negotiated Rate	$0.76
Max. Negotiated Rate	$8.66
Rate for Payer: Aetna of NY Medicare	$4.98
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$4.33
Rate for Payer: Cash Price	$8.12
Rate for Payer: Cash Price	$8.12
Rate for Payer: CDPHP Medicare	$4.00
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$0.76
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$8.66
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$8.66
Rate for Payer: EmblemHealth Medicaid	$8.66
Rate for Payer: EmblemHealth Medicare	$3.68
Rate for Payer: EmblemHealth Select Care	$0.76
Rate for Payer: Fidelis Medicare	$4.33
Rate for Payer: Galaxy Health Commercial	$7.03
Rate for Payer: Hamaspik Choice Medicare	$4.33
Rate for Payer: Humana Medicare	$4.33
Rate for Payer: Local 1199SEIU Medicare	$4.98
Rate for Payer: MVP Health Care of NY Commercial	$8.12
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$6.09
Rate for Payer: MVP Health Care of NY Medicare	$4.54
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$3.23
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$1.62
Rate for Payer: United Healthcare Commercial	$3.23
Rate for Payer: United Healthcare Medicare	$4.33
Rate for Payer: WellCare Medicare	$5.95

CIPROFLOXACIN IV INJ 200 MG

Facility

$10.82

Service Code	HCPCS J0744
Hospital Charge Code	4450002
Hospital Revenue Code	636
Min. Negotiated Rate	$0.76
Max. Negotiated Rate	$7.03
Rate for Payer: Aetna of NY Commercial	$5.95
Rate for Payer: Cash Price	$8.12
Rate for Payer: Cash Price	$8.12
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$0.76
Rate for Payer: EmblemHealth Select Care	$0.76
Rate for Payer: Galaxy Health Commercial	$7.03
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$5.95
Rate for Payer: WellCare Medicare	$5.95

CIPROFLOXACIN OS

Facility

$76.99

Service Code	NDC 61314065625
Hospital Charge Code	4409050
Hospital Revenue Code	250
Min. Negotiated Rate	$11.55
Max. Negotiated Rate	$61.59
Rate for Payer: Aetna of NY Commercial	$53.89
Rate for Payer: Aetna of NY Medicare	$35.42
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$30.80
Rate for Payer: Cash Price	$57.74
Rate for Payer: CDPHP Medicare	$28.49
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$61.59
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$61.59
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$61.59
Rate for Payer: EmblemHealth Medicaid	$61.59
Rate for Payer: EmblemHealth Medicare	$26.18
Rate for Payer: EmblemHealth Select Care	$55.43
Rate for Payer: Fidelis Medicare	$30.80
Rate for Payer: Galaxy Health Commercial	$50.04
Rate for Payer: Hamaspik Choice Medicare	$30.80
Rate for Payer: Humana Medicare	$30.80
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$53.89
Rate for Payer: Local 1199SEIU Medicare	$35.42
Rate for Payer: MVP Health Care of NY Commercial	$57.74
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$43.35
Rate for Payer: MVP Health Care of NY Medicare	$32.34
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$11.55
Rate for Payer: United Healthcare Medicare	$30.80
Rate for Payer: WellCare Medicare	$42.34

CIPROFLOXACIN OS

Facility

$76.99

Service Code	NDC 61314065625
Hospital Charge Code	4409050
Hospital Revenue Code	250
Min. Negotiated Rate	$42.34
Max. Negotiated Rate	$50.04
Rate for Payer: Cash Price	$57.74
Rate for Payer: Galaxy Health Commercial	$50.04
Rate for Payer: WellCare Medicare	$42.34

CIRCUMCISION AGE >28 DAYS

Facility

$6,407.00

Service Code	HCPCS 54161
Hospital Charge Code	4002047
Hospital Revenue Code	490
Min. Negotiated Rate	$961.05
Max. Negotiated Rate	$5,125.60
Rate for Payer: Aetna of NY Commercial	$1,900.00
Rate for Payer: Aetna of NY Medicare	$2,947.22
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$2,562.80
Rate for Payer: Cash Price	$4,805.25
Rate for Payer: Cash Price	$4,805.25
Rate for Payer: CDPHP Medicare	$2,370.59
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$5,125.60
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$5,125.60
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$5,125.60
Rate for Payer: EmblemHealth Medicaid	$5,125.60
Rate for Payer: EmblemHealth Medicare	$2,178.38
Rate for Payer: EmblemHealth Select Care	$4,613.04
Rate for Payer: Fidelis Medicare	$2,562.80
Rate for Payer: Galaxy Health Commercial	$4,164.55
Rate for Payer: Hamaspik Choice Medicare	$2,562.80
Rate for Payer: Humana Medicare	$2,562.80
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$1,900.00
Rate for Payer: Local 1199SEIU Medicare	$2,947.22
Rate for Payer: Multiplan Commercial	$5,125.60
Rate for Payer: MVP Health Care of NY Commercial	$4,805.25
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$3,607.14
Rate for Payer: MVP Health Care of NY Medicare	$2,690.94
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$2,097.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$961.05
Rate for Payer: United Healthcare Commercial	$2,097.00
Rate for Payer: United Healthcare Medicare	$2,562.80
Rate for Payer: WellCare Medicare	$3,523.85

CIRCUMCISION AGE >28 DAYS

Facility

$6,407.00

Service Code	HCPCS 54161
Hospital Charge Code	4002047
Hospital Revenue Code	490
Min. Negotiated Rate	$4,164.55
Max. Negotiated Rate	$4,164.55
Rate for Payer: Cash Price	$4,805.25
Rate for Payer: Galaxy Health Commercial	$4,164.55

CISTERNOGRAPHY

Facility

$1,664.00

Service Code	HCPCS 78630
Hospital Charge Code	4210010
Hospital Revenue Code	341
Min. Negotiated Rate	$1,081.60
Max. Negotiated Rate	$1,081.60
Rate for Payer: Cash Price	$1,248.00
Rate for Payer: Galaxy Health Commercial	$1,081.60

CISTERNOGRAPHY

Facility

$98.00

Service Code	HCPCS 78630 26
Hospital Charge Code	5210010
Hospital Revenue Code	960
Min. Negotiated Rate	$14.70
Max. Negotiated Rate	$78.40
Rate for Payer: Aetna of NY Commercial	$68.60
Rate for Payer: Aetna of NY Medicare	$45.08
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$39.20
Rate for Payer: Cash Price	$73.50
Rate for Payer: CDPHP Medicare	$36.26
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$78.40
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$78.40
Rate for Payer: EmblemHealth Medicaid	$78.40
Rate for Payer: EmblemHealth Medicare	$33.32
Rate for Payer: Fidelis Medicare	$39.20
Rate for Payer: Galaxy Health Commercial	$63.70
Rate for Payer: Hamaspik Choice Medicare	$39.20
Rate for Payer: Humana Medicare	$39.20
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$68.60
Rate for Payer: Local 1199SEIU Medicare	$45.08
Rate for Payer: MVP Health Care of NY Commercial	$73.50
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$55.17
Rate for Payer: MVP Health Care of NY Medicare	$41.16
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$14.70
Rate for Payer: United Healthcare Medicare	$39.20
Rate for Payer: WellCare Medicare	$53.90

CISTERNOGRAPHY

Facility

$98.00

Service Code	HCPCS 78630 26
Hospital Charge Code	5210010
Hospital Revenue Code	960
Min. Negotiated Rate	$63.70
Max. Negotiated Rate	$63.70
Rate for Payer: Cash Price	$73.50
Rate for Payer: Galaxy Health Commercial	$63.70

CISTERNOGRAPHY

Facility

$1,664.00

Service Code	HCPCS 78630
Hospital Charge Code	4210010
Hospital Revenue Code	341
Min. Negotiated Rate	$249.60
Max. Negotiated Rate	$1,545.00
Rate for Payer: Aetna of NY Commercial	$1,164.80
Rate for Payer: Aetna of NY Medicare	$765.44
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$665.60
Rate for Payer: Cash Price	$1,248.00
Rate for Payer: Cash Price	$1,248.00
Rate for Payer: CDPHP Medicare	$615.68
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$1,164.80
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$1,331.20
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$1,331.20
Rate for Payer: EmblemHealth Medicaid	$1,331.20
Rate for Payer: EmblemHealth Medicare	$565.76
Rate for Payer: EmblemHealth Select Care	$1,081.60
Rate for Payer: Fidelis Medicare	$665.60
Rate for Payer: Galaxy Health Commercial	$1,081.60
Rate for Payer: Hamaspik Choice Medicare	$665.60
Rate for Payer: Humana Medicare	$665.60
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$1,164.80
Rate for Payer: Local 1199SEIU Medicare	$765.44
Rate for Payer: MVP Health Care of NY Commercial	$1,248.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$936.83
Rate for Payer: MVP Health Care of NY Medicare	$698.88
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$1,545.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$249.60
Rate for Payer: United Healthcare Commercial	$1,545.00
Rate for Payer: United Healthcare Medicare	$665.60
Rate for Payer: WellCare Medicare	$915.20

CITALOPRAM HYDROBROMIDE 10MG TABS 10X10E

Facility

$7.47

Service Code	NDC 904608461
Hospital Charge Code	4400164
Hospital Revenue Code	250
Min. Negotiated Rate	$4.11
Max. Negotiated Rate	$4.86
Rate for Payer: Cash Price	$5.60
Rate for Payer: Galaxy Health Commercial	$4.86
Rate for Payer: WellCare Medicare	$4.11

CITALOPRAM HYDROBROMIDE 10MG TABS 10X10E

Facility

$7.47

Service Code	NDC 904608461
Hospital Charge Code	4400164
Hospital Revenue Code	250
Min. Negotiated Rate	$1.12
Max. Negotiated Rate	$5.98
Rate for Payer: Aetna of NY Commercial	$5.23
Rate for Payer: Aetna of NY Medicare	$3.44
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$2.99
Rate for Payer: Cash Price	$5.60
Rate for Payer: CDPHP Medicare	$2.76
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$5.98
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$5.98
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$5.98
Rate for Payer: EmblemHealth Medicaid	$5.98
Rate for Payer: EmblemHealth Medicare	$2.54
Rate for Payer: EmblemHealth Select Care	$5.38
Rate for Payer: Fidelis Medicare	$2.99
Rate for Payer: Galaxy Health Commercial	$4.86
Rate for Payer: Hamaspik Choice Medicare	$2.99
Rate for Payer: Humana Medicare	$2.99
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$5.23
Rate for Payer: Local 1199SEIU Medicare	$3.44
Rate for Payer: MVP Health Care of NY Commercial	$5.60
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$4.21
Rate for Payer: MVP Health Care of NY Medicare	$3.14
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$1.12
Rate for Payer: United Healthcare Medicare	$2.99
Rate for Payer: WellCare Medicare	$4.11

CITALOPRAM HYDROBROMIDE 40MG TABS 10X10E

Facility

$10.82

Service Code	NDC 904608661
Hospital Charge Code	4400166
Hospital Revenue Code	250
Min. Negotiated Rate	$1.62
Max. Negotiated Rate	$8.66
Rate for Payer: Aetna of NY Commercial	$7.57
Rate for Payer: Aetna of NY Medicare	$4.98
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$4.33
Rate for Payer: Cash Price	$8.12
Rate for Payer: CDPHP Medicare	$4.00
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$8.66
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$8.66
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$8.66
Rate for Payer: EmblemHealth Medicaid	$8.66
Rate for Payer: EmblemHealth Medicare	$3.68
Rate for Payer: EmblemHealth Select Care	$7.79
Rate for Payer: Fidelis Medicare	$4.33
Rate for Payer: Galaxy Health Commercial	$7.03
Rate for Payer: Hamaspik Choice Medicare	$4.33
Rate for Payer: Humana Medicare	$4.33
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$7.57
Rate for Payer: Local 1199SEIU Medicare	$4.98
Rate for Payer: MVP Health Care of NY Commercial	$8.12
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$6.09
Rate for Payer: MVP Health Care of NY Medicare	$4.54
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$1.62
Rate for Payer: United Healthcare Medicare	$4.33
Rate for Payer: WellCare Medicare	$5.95

CITALOPRAM HYDROBROMIDE 40MG TABS 10X10E

Facility

$10.82

Service Code	NDC 904608661
Hospital Charge Code	4400166
Hospital Revenue Code	250
Min. Negotiated Rate	$5.95
Max. Negotiated Rate	$7.03
Rate for Payer: Cash Price	$8.12
Rate for Payer: Galaxy Health Commercial	$7.03
Rate for Payer: WellCare Medicare	$5.95

CLARITHROMYCIN 500 MG TABLET

Facility

$19.06

Service Code	NDC 68084065195
Hospital Charge Code	4409103
Hospital Revenue Code	250
Min. Negotiated Rate	$10.48
Max. Negotiated Rate	$12.39
Rate for Payer: Cash Price	$14.29
Rate for Payer: Galaxy Health Commercial	$12.39
Rate for Payer: WellCare Medicare	$10.48

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