Ellenville Regional Hospital

All Charges

Charge

Type

Setting

Price

DIPYRIDAMOLE 25 MG TAB

Facility

$6.18

Service Code	NDC 64980013301
Hospital Charge Code	4409110
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

DIRECT LDL

Facility

$37.00

Service Code	HCPCS 83721
Hospital Charge Code	4300273
Hospital Revenue Code	301
Min. Negotiated Rate	$10.50
Max. Negotiated Rate	$29.78
Rate for Payer: Aetna of NY Commercial	$24.05
Rate for Payer: Aetna of NY Medicare	$17.02
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group	$27.75
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO	$27.75
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$13.69
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp	$18.50
Rate for Payer: Cash Price	$27.75
Rate for Payer: Cash Price	$27.75
Rate for Payer: CDPHP Commercial	$29.78
Rate for Payer: CDPHP Medicare	$13.69
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$22.20
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$29.60
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$29.60
Rate for Payer: EmblemHealth Medicaid	$29.60
Rate for Payer: EmblemHealth Medicare	$12.58
Rate for Payer: EmblemHealth Select Care	$22.20
Rate for Payer: Fidelis Medicare	$14.10
Rate for Payer: Galaxy Health Commercial	$24.05
Rate for Payer: Hamaspik Choice Medicare	$13.69
Rate for Payer: Humana Medicare	$13.69
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$24.05
Rate for Payer: Local 1199SEIU Medicare	$17.02
Rate for Payer: MVP Health Care of NY Commercial	$27.75
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$20.83
Rate for Payer: MVP Health Care of NY Medicare	$14.37
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$27.75
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$10.50
Rate for Payer: United Healthcare Commercial	$27.75
Rate for Payer: United Healthcare Medicare	$13.69
Rate for Payer: WellCare Medicare	$20.35

DIRECT LDL

Facility

$37.00

Service Code	HCPCS 83721
Hospital Charge Code	4300273
Hospital Revenue Code	301
Min. Negotiated Rate	$24.05
Max. Negotiated Rate	$24.05
Rate for Payer: Cash Price	$27.75
Rate for Payer: Galaxy Health Commercial	$24.05

DISP BIOPSY FORCEPS - SPIKED

Facility

$36.00

Hospital Charge Code	4471833
Hospital Revenue Code	270
Min. Negotiated Rate	$23.40
Max. Negotiated Rate	$23.40
Rate for Payer: Cash Price	$27.00
Rate for Payer: Galaxy Health Commercial	$23.40

DISP BIOPSY FORCEPS - SPIKED

Facility

$36.00

Hospital Charge Code	4471833
Hospital Revenue Code	270
Min. Negotiated Rate	$12.24
Max. Negotiated Rate	$28.98
Rate for Payer: Aetna of NY Commercial	$25.20
Rate for Payer: Aetna of NY Medicare	$16.56
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group	$27.00
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO	$27.00
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$13.32
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp	$18.00
Rate for Payer: Cash Price	$27.00
Rate for Payer: CDPHP Commercial	$28.98
Rate for Payer: CDPHP Medicare	$13.32
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$28.80
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$28.80
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$28.80
Rate for Payer: EmblemHealth Medicaid	$28.80
Rate for Payer: EmblemHealth Medicare	$12.24
Rate for Payer: EmblemHealth Select Care	$25.92
Rate for Payer: Fidelis Medicare	$13.72
Rate for Payer: Galaxy Health Commercial	$23.40
Rate for Payer: Hamaspik Choice Medicare	$13.32
Rate for Payer: Humana Medicare	$13.32
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$25.20
Rate for Payer: Local 1199SEIU Medicare	$16.56
Rate for Payer: MVP Health Care of NY Commercial	$27.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$20.27
Rate for Payer: MVP Health Care of NY Medicare	$13.99
Rate for Payer: United Healthcare Medicare	$13.32
Rate for Payer: WellCare Medicare	$19.80

DISP DUAL-INCI FALOPE-RING BAND 8MM W T

Facility

$923.00

Hospital Charge Code	4479084
Hospital Revenue Code	270
Min. Negotiated Rate	$599.95
Max. Negotiated Rate	$599.95
Rate for Payer: Cash Price	$692.25
Rate for Payer: Galaxy Health Commercial	$599.95

DISP DUAL-INCI FALOPE-RING BAND 8MM W T

Facility

$923.00

Hospital Charge Code	4479084
Hospital Revenue Code	270
Min. Negotiated Rate	$313.82
Max. Negotiated Rate	$743.02
Rate for Payer: Aetna of NY Commercial	$646.10
Rate for Payer: Aetna of NY Medicare	$424.58
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group	$692.25
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO	$692.25
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$341.51
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp	$461.50
Rate for Payer: Cash Price	$692.25
Rate for Payer: CDPHP Commercial	$743.02
Rate for Payer: CDPHP Medicare	$341.51
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$738.40
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$738.40
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$738.40
Rate for Payer: EmblemHealth Medicaid	$738.40
Rate for Payer: EmblemHealth Medicare	$313.82
Rate for Payer: EmblemHealth Select Care	$664.56
Rate for Payer: Fidelis Medicare	$351.76
Rate for Payer: Galaxy Health Commercial	$599.95
Rate for Payer: Hamaspik Choice Medicare	$341.51
Rate for Payer: Humana Medicare	$341.51
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$646.10
Rate for Payer: Local 1199SEIU Medicare	$424.58
Rate for Payer: MVP Health Care of NY Commercial	$692.25
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$519.65
Rate for Payer: MVP Health Care of NY Medicare	$358.59
Rate for Payer: United Healthcare Medicare	$341.51
Rate for Payer: WellCare Medicare	$507.65

DISP DUAL-INCI FALOPE-RING BAND W/O TRO

Facility

$651.00

Hospital Charge Code	4479085
Hospital Revenue Code	270
Min. Negotiated Rate	$221.34
Max. Negotiated Rate	$524.06
Rate for Payer: Aetna of NY Commercial	$455.70
Rate for Payer: Aetna of NY Medicare	$299.46
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group	$488.25
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO	$488.25
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$240.87
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp	$325.50
Rate for Payer: Cash Price	$488.25
Rate for Payer: CDPHP Commercial	$524.06
Rate for Payer: CDPHP Medicare	$240.87
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$520.80
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$520.80
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$520.80
Rate for Payer: EmblemHealth Medicaid	$520.80
Rate for Payer: EmblemHealth Medicare	$221.34
Rate for Payer: EmblemHealth Select Care	$468.72
Rate for Payer: Fidelis Medicare	$248.10
Rate for Payer: Galaxy Health Commercial	$423.15
Rate for Payer: Hamaspik Choice Medicare	$240.87
Rate for Payer: Humana Medicare	$240.87
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$455.70
Rate for Payer: Local 1199SEIU Medicare	$299.46
Rate for Payer: MVP Health Care of NY Commercial	$488.25
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$366.51
Rate for Payer: MVP Health Care of NY Medicare	$252.91
Rate for Payer: United Healthcare Medicare	$240.87
Rate for Payer: WellCare Medicare	$358.05

DISP DUAL-INCI FALOPE-RING BAND W/O TRO

Facility

$651.00

Hospital Charge Code	4479085
Hospital Revenue Code	270
Min. Negotiated Rate	$423.15
Max. Negotiated Rate	$423.15
Rate for Payer: Cash Price	$488.25
Rate for Payer: Galaxy Health Commercial	$423.15

DISPERSIVE ELECTRODE: PMA-GP-BAY 4479209

Facility

$347.00

Hospital Charge Code	4479209
Hospital Revenue Code	270
Min. Negotiated Rate	$117.98
Max. Negotiated Rate	$279.34
Rate for Payer: Aetna of NY Commercial	$242.90
Rate for Payer: Aetna of NY Medicare	$159.62
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group	$260.25
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO	$260.25
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$128.39
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp	$173.50
Rate for Payer: Cash Price	$260.25
Rate for Payer: CDPHP Commercial	$279.34
Rate for Payer: CDPHP Medicare	$128.39
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$277.60
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$277.60
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$277.60
Rate for Payer: EmblemHealth Medicaid	$277.60
Rate for Payer: EmblemHealth Medicare	$117.98
Rate for Payer: EmblemHealth Select Care	$249.84
Rate for Payer: Fidelis Medicare	$132.24
Rate for Payer: Galaxy Health Commercial	$225.55
Rate for Payer: Hamaspik Choice Medicare	$128.39
Rate for Payer: Humana Medicare	$128.39
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$242.90
Rate for Payer: Local 1199SEIU Medicare	$159.62
Rate for Payer: MVP Health Care of NY Commercial	$260.25
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$195.36
Rate for Payer: MVP Health Care of NY Medicare	$134.81
Rate for Payer: United Healthcare Medicare	$128.39
Rate for Payer: WellCare Medicare	$190.85

DISPERSIVE ELECTRODE: PMA-GP-BAY 4479209

Facility

$347.00

Hospital Charge Code	4479209
Hospital Revenue Code	270
Min. Negotiated Rate	$225.55
Max. Negotiated Rate	$225.55
Rate for Payer: Cash Price	$260.25
Rate for Payer: Galaxy Health Commercial	$225.55

DISP HIGH FLOW INSULFLATOR

Facility

$53.00

Hospital Charge Code	4471447
Hospital Revenue Code	270
Min. Negotiated Rate	$34.45
Max. Negotiated Rate	$34.45
Rate for Payer: Cash Price	$39.75
Rate for Payer: Galaxy Health Commercial	$34.45

DISP HIGH FLOW INSULFLATOR

Facility

$53.00

Hospital Charge Code	4471447
Hospital Revenue Code	270
Min. Negotiated Rate	$18.02
Max. Negotiated Rate	$42.66
Rate for Payer: Aetna of NY Commercial	$37.10
Rate for Payer: Aetna of NY Medicare	$24.38
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group	$39.75
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO	$39.75
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$19.61
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp	$26.50
Rate for Payer: Cash Price	$39.75
Rate for Payer: CDPHP Commercial	$42.66
Rate for Payer: CDPHP Medicare	$19.61
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$42.40
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$42.40
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$42.40
Rate for Payer: EmblemHealth Medicaid	$42.40
Rate for Payer: EmblemHealth Medicare	$18.02
Rate for Payer: EmblemHealth Select Care	$38.16
Rate for Payer: Fidelis Medicare	$20.20
Rate for Payer: Galaxy Health Commercial	$34.45
Rate for Payer: Hamaspik Choice Medicare	$19.61
Rate for Payer: Humana Medicare	$19.61
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$37.10
Rate for Payer: Local 1199SEIU Medicare	$24.38
Rate for Payer: MVP Health Care of NY Commercial	$39.75
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$29.84
Rate for Payer: MVP Health Care of NY Medicare	$20.59
Rate for Payer: United Healthcare Medicare	$19.61
Rate for Payer: WellCare Medicare	$29.15

DISPOSABLE GAIT BELTS

Facility

$15.00

Hospital Charge Code	4479203
Hospital Revenue Code	270
Min. Negotiated Rate	$9.75
Max. Negotiated Rate	$9.75
Rate for Payer: Cash Price	$11.25
Rate for Payer: Galaxy Health Commercial	$9.75

DISPOSABLE GAIT BELTS

Facility

$15.00

Hospital Charge Code	4479203
Hospital Revenue Code	270
Min. Negotiated Rate	$5.10
Max. Negotiated Rate	$12.08
Rate for Payer: Aetna of NY Commercial	$10.50
Rate for Payer: Aetna of NY Medicare	$6.90
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group	$11.25
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO	$11.25
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$5.55
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp	$7.50
Rate for Payer: Cash Price	$11.25
Rate for Payer: CDPHP Commercial	$12.08
Rate for Payer: CDPHP Medicare	$5.55
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$12.00
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$12.00
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$12.00
Rate for Payer: EmblemHealth Medicaid	$12.00
Rate for Payer: EmblemHealth Medicare	$5.10
Rate for Payer: EmblemHealth Select Care	$10.80
Rate for Payer: Fidelis Medicare	$5.72
Rate for Payer: Galaxy Health Commercial	$9.75
Rate for Payer: Hamaspik Choice Medicare	$5.55
Rate for Payer: Humana Medicare	$5.55
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$10.50
Rate for Payer: Local 1199SEIU Medicare	$6.90
Rate for Payer: MVP Health Care of NY Commercial	$11.25
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$8.44
Rate for Payer: MVP Health Care of NY Medicare	$5.83
Rate for Payer: United Healthcare Medicare	$5.55
Rate for Payer: WellCare Medicare	$8.25

DISPOSIBLE SCLEROTHERAPY NEEDL

Facility

$107.00

Hospital Charge Code	4471000
Hospital Revenue Code	270
Min. Negotiated Rate	$69.55
Max. Negotiated Rate	$69.55
Rate for Payer: Cash Price	$80.25
Rate for Payer: Galaxy Health Commercial	$69.55

DISPOSIBLE SCLEROTHERAPY NEEDL

Facility

$107.00

Hospital Charge Code	4471000
Hospital Revenue Code	270
Min. Negotiated Rate	$36.38
Max. Negotiated Rate	$86.14
Rate for Payer: Aetna of NY Commercial	$74.90
Rate for Payer: Aetna of NY Medicare	$49.22
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group	$80.25
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO	$80.25
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$39.59
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp	$53.50
Rate for Payer: Cash Price	$80.25
Rate for Payer: CDPHP Commercial	$86.14
Rate for Payer: CDPHP Medicare	$39.59
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$85.60
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$85.60
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$85.60
Rate for Payer: EmblemHealth Medicaid	$85.60
Rate for Payer: EmblemHealth Medicare	$36.38
Rate for Payer: EmblemHealth Select Care	$77.04
Rate for Payer: Fidelis Medicare	$40.78
Rate for Payer: Galaxy Health Commercial	$69.55
Rate for Payer: Hamaspik Choice Medicare	$39.59
Rate for Payer: Humana Medicare	$39.59
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$74.90
Rate for Payer: Local 1199SEIU Medicare	$49.22
Rate for Payer: MVP Health Care of NY Commercial	$80.25
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$60.24
Rate for Payer: MVP Health Care of NY Medicare	$41.57
Rate for Payer: United Healthcare Medicare	$39.59
Rate for Payer: WellCare Medicare	$58.85

DIVALPROEX DR 250 MG TABLET

Facility

$1.00

Service Code	NDC 68084077611
Hospital Charge Code	4401291
Hospital Revenue Code	250
Min. Negotiated Rate	$0.55
Max. Negotiated Rate	$0.65
Rate for Payer: Cash Price	$0.75
Rate for Payer: Galaxy Health Commercial	$0.65
Rate for Payer: WellCare Medicare	$0.55

DIVALPROEX DR 250 MG TABLET

Facility

$1.00

Service Code	NDC 68084077611
Hospital Charge Code	4401291
Hospital Revenue Code	250
Min. Negotiated Rate	$0.34
Max. Negotiated Rate	$0.81
Rate for Payer: Aetna of NY Commercial	$0.70
Rate for Payer: Aetna of NY Medicare	$0.46
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group	$0.75
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO	$0.75
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$0.37
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp	$0.50
Rate for Payer: Cash Price	$0.75
Rate for Payer: CDPHP Commercial	$0.81
Rate for Payer: CDPHP Medicare	$0.37
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$0.80
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$0.80
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$0.80
Rate for Payer: EmblemHealth Medicaid	$0.80
Rate for Payer: EmblemHealth Medicare	$0.34
Rate for Payer: EmblemHealth Select Care	$0.72
Rate for Payer: Fidelis Medicare	$0.38
Rate for Payer: Galaxy Health Commercial	$0.65
Rate for Payer: Hamaspik Choice Medicare	$0.37
Rate for Payer: Humana Medicare	$0.37
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$0.70
Rate for Payer: Local 1199SEIU Medicare	$0.46
Rate for Payer: MVP Health Care of NY Commercial	$0.75
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$0.56
Rate for Payer: MVP Health Care of NY Medicare	$0.39
Rate for Payer: United Healthcare Medicare	$0.37
Rate for Payer: WellCare Medicare	$0.55

DIVALPROEX SOD ER 250 MG TAB 250 mg, 100 eaches

Facility

$6.00

Service Code	NDC 00904636361
Hospital Charge Code	4401365
Hospital Revenue Code	250
Min. Negotiated Rate	$2.04
Max. Negotiated Rate	$4.83
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) Blue Access/Small Group	$4.50
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO	$4.50
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$2.22
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp	$3.00
Rate for Payer: Cash Price	$4.50
Rate for Payer: CDPHP Commercial	$4.83
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	$2.29
Rate for Payer: Galaxy Health Commercial	$3.90
Rate for Payer: Hamaspik Choice Medicare	$2.22
Rate for Payer: Humana Medicare	$2.22
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	$2.33
Rate for Payer: United Healthcare Medicare	$2.22
Rate for Payer: WellCare Medicare	$3.30

DIVALPROEX SOD ER 250 MG TAB 250 mg, 100 eaches

Facility

$6.00

Service Code	NDC 00904636361
Hospital Charge Code	4401365
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

DNA/RNA; MULTI ORG - AMP PR

Facility

$246.00

Service Code	HCPCS 87801
Hospital Charge Code	4302007
Hospital Revenue Code	300
Min. Negotiated Rate	$159.90
Max. Negotiated Rate	$159.90
Rate for Payer: Cash Price	$184.50
Rate for Payer: Galaxy Health Commercial	$159.90

DNA/RNA; MULTI ORG - AMP PR

Facility

$246.00

Service Code	HCPCS 87801
Hospital Charge Code	4302007
Hospital Revenue Code	300
Min. Negotiated Rate	$40.40
Max. Negotiated Rate	$198.03
Rate for Payer: Aetna of NY Commercial	$159.90
Rate for Payer: Aetna of NY Medicare	$113.16
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group	$184.50
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO	$184.50
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$91.02
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp	$123.00
Rate for Payer: Cash Price	$184.50
Rate for Payer: Cash Price	$184.50
Rate for Payer: CDPHP Commercial	$198.03
Rate for Payer: CDPHP Medicare	$91.02
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$147.60
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$196.80
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$196.80
Rate for Payer: EmblemHealth Medicaid	$196.80
Rate for Payer: EmblemHealth Medicare	$83.64
Rate for Payer: EmblemHealth Select Care	$147.60
Rate for Payer: Fidelis Medicare	$93.75
Rate for Payer: Galaxy Health Commercial	$159.90
Rate for Payer: Hamaspik Choice Medicare	$91.02
Rate for Payer: Humana Medicare	$91.02
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$159.90
Rate for Payer: Local 1199SEIU Medicare	$113.16
Rate for Payer: MVP Health Care of NY Commercial	$184.50
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$138.50
Rate for Payer: MVP Health Care of NY Medicare	$95.57
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$184.50
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$40.40
Rate for Payer: United Healthcare Commercial	$184.50
Rate for Payer: United Healthcare Medicare	$91.02
Rate for Payer: WellCare Medicare	$135.30

DOBUTAMINE 5%DEXTROSE 250MG

Facility

$7.00

Hospital Charge Code	4471209
Hospital Revenue Code	270
Min. Negotiated Rate	$2.38
Max. Negotiated Rate	$5.64
Rate for Payer: Aetna of NY Commercial	$4.90
Rate for Payer: Aetna of NY Medicare	$3.22
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group	$5.25
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO	$5.25
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$2.59
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp	$3.50
Rate for Payer: Cash Price	$5.25
Rate for Payer: CDPHP Commercial	$5.64
Rate for Payer: CDPHP Medicare	$2.59
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$5.60
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$5.60
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$5.60
Rate for Payer: EmblemHealth Medicaid	$5.60
Rate for Payer: EmblemHealth Medicare	$2.38
Rate for Payer: EmblemHealth Select Care	$5.04
Rate for Payer: Fidelis Medicare	$2.67
Rate for Payer: Galaxy Health Commercial	$4.55
Rate for Payer: Hamaspik Choice Medicare	$2.59
Rate for Payer: Humana Medicare	$2.59
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$4.90
Rate for Payer: Local 1199SEIU Medicare	$3.22
Rate for Payer: MVP Health Care of NY Commercial	$5.25
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$3.94
Rate for Payer: MVP Health Care of NY Medicare	$2.72
Rate for Payer: United Healthcare Medicare	$2.59
Rate for Payer: WellCare Medicare	$3.85

DOBUTAMINE 5%DEXTROSE 250MG

Facility

$7.00

Hospital Charge Code	4471209
Hospital Revenue Code	270
Min. Negotiated Rate	$4.55
Max. Negotiated Rate	$4.55
Rate for Payer: Cash Price	$5.25
Rate for Payer: Galaxy Health Commercial	$4.55

Know your out-of-pocket cost for care.

All Charges