Ellenville Regional Hospital

All Charges

Charge

Type

Setting

Price

DILAT FEMALE URETHRA W/SUPPOSITORY&/INSTLJ INI

Facility

$469.00

Service Code	HCPCS 53660
Hospital Charge Code	4002037
Hospital Revenue Code	490
Min. Negotiated Rate	$70.35
Max. Negotiated Rate	$1,900.00
Rate for Payer: Aetna of NY Commercial	$1,900.00
Rate for Payer: Aetna of NY Medicare	$215.74
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$187.60
Rate for Payer: Cash Price	$351.75
Rate for Payer: Cash Price	$351.75
Rate for Payer: CDPHP Medicare	$173.53
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$375.20
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$375.20
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$375.20
Rate for Payer: EmblemHealth Medicaid	$375.20
Rate for Payer: EmblemHealth Medicare	$159.46
Rate for Payer: EmblemHealth Select Care	$337.68
Rate for Payer: Fidelis Medicare	$187.60
Rate for Payer: Galaxy Health Commercial	$304.85
Rate for Payer: Hamaspik Choice Medicare	$187.60
Rate for Payer: Humana Medicare	$187.60
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$1,900.00
Rate for Payer: Local 1199SEIU Medicare	$215.74
Rate for Payer: Multiplan Commercial	$375.20
Rate for Payer: MVP Health Care of NY Commercial	$351.75
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$264.05
Rate for Payer: MVP Health Care of NY Medicare	$196.98
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$1,828.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$70.35
Rate for Payer: United Healthcare Commercial	$1,828.00
Rate for Payer: United Healthcare Medicare	$187.60
Rate for Payer: WellCare Medicare	$257.95

DILATION SYRINGE 60CC

Facility

$129.78

Hospital Charge Code	4471843
Hospital Revenue Code	270
Min. Negotiated Rate	$84.36
Max. Negotiated Rate	$84.36
Rate for Payer: Cash Price	$97.34
Rate for Payer: Galaxy Health Commercial	$84.36

DILATION SYRINGE 60CC

Facility

$129.78

Hospital Charge Code	4471843
Hospital Revenue Code	270
Min. Negotiated Rate	$19.47
Max. Negotiated Rate	$103.82
Rate for Payer: Aetna of NY Commercial	$90.85
Rate for Payer: Aetna of NY Medicare	$59.70
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$51.91
Rate for Payer: Cash Price	$97.34
Rate for Payer: CDPHP Medicare	$48.02
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$103.82
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$103.82
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$103.82
Rate for Payer: EmblemHealth Medicaid	$103.82
Rate for Payer: EmblemHealth Medicare	$44.13
Rate for Payer: EmblemHealth Select Care	$93.44
Rate for Payer: Fidelis Medicare	$51.91
Rate for Payer: Galaxy Health Commercial	$84.36
Rate for Payer: Hamaspik Choice Medicare	$51.91
Rate for Payer: Humana Medicare	$51.91
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$90.85
Rate for Payer: Local 1199SEIU Medicare	$59.70
Rate for Payer: MVP Health Care of NY Commercial	$97.33
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$73.07
Rate for Payer: MVP Health Care of NY Medicare	$54.51
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$19.47
Rate for Payer: United Healthcare Medicare	$51.91
Rate for Payer: WellCare Medicare	$71.38

DILAT URETHRAL STRIX DILATOR MALE 1ST

Facility

$766.00

Service Code	HCPCS 53600
Hospital Charge Code	4002035
Hospital Revenue Code	490
Min. Negotiated Rate	$497.90
Max. Negotiated Rate	$497.90
Rate for Payer: Cash Price	$574.50
Rate for Payer: Galaxy Health Commercial	$497.90

DILAT URETHRAL STRIX DILATOR MALE 1ST

Facility

$766.00

Service Code	HCPCS 53600
Hospital Charge Code	4002035
Hospital Revenue Code	490
Min. Negotiated Rate	$114.90
Max. Negotiated Rate	$1,900.00
Rate for Payer: Aetna of NY Commercial	$1,900.00
Rate for Payer: Aetna of NY Medicare	$352.36
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$306.40
Rate for Payer: Cash Price	$574.50
Rate for Payer: Cash Price	$574.50
Rate for Payer: CDPHP Medicare	$283.42
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$612.80
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$612.80
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$612.80
Rate for Payer: EmblemHealth Medicaid	$612.80
Rate for Payer: EmblemHealth Medicare	$260.44
Rate for Payer: EmblemHealth Select Care	$551.52
Rate for Payer: Fidelis Medicare	$306.40
Rate for Payer: Galaxy Health Commercial	$497.90
Rate for Payer: Hamaspik Choice Medicare	$306.40
Rate for Payer: Humana Medicare	$306.40
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$1,900.00
Rate for Payer: Local 1199SEIU Medicare	$352.36
Rate for Payer: Multiplan Commercial	$612.80
Rate for Payer: MVP Health Care of NY Commercial	$574.50
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$431.26
Rate for Payer: MVP Health Care of NY Medicare	$321.72
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$1,828.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$114.90
Rate for Payer: United Healthcare Commercial	$1,828.00
Rate for Payer: United Healthcare Medicare	$306.40
Rate for Payer: WellCare Medicare	$421.30

DILAT URETHRAL STRIX/VESICAL NCK DILAT MALE ANES

Facility

$10,804.00

Service Code	HCPCS 53605
Hospital Charge Code	4002036
Hospital Revenue Code	490
Min. Negotiated Rate	$7,022.60
Max. Negotiated Rate	$7,022.60
Rate for Payer: Cash Price	$8,103.00
Rate for Payer: Galaxy Health Commercial	$7,022.60

DILAT URETHRAL STRIX/VESICAL NCK DILAT MALE ANES

Facility

$10,804.00

Service Code	HCPCS 53605
Hospital Charge Code	4002036
Hospital Revenue Code	490
Min. Negotiated Rate	$1,620.60
Max. Negotiated Rate	$8,643.20
Rate for Payer: Aetna of NY Commercial	$1,900.00
Rate for Payer: Aetna of NY Medicare	$4,969.84
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$4,321.60
Rate for Payer: Cash Price	$8,103.00
Rate for Payer: Cash Price	$8,103.00
Rate for Payer: CDPHP Medicare	$3,997.48
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$8,643.20
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$8,643.20
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$8,643.20
Rate for Payer: EmblemHealth Medicaid	$8,643.20
Rate for Payer: EmblemHealth Medicare	$3,673.36
Rate for Payer: EmblemHealth Select Care	$7,778.88
Rate for Payer: Fidelis Medicare	$4,321.60
Rate for Payer: Galaxy Health Commercial	$7,022.60
Rate for Payer: Hamaspik Choice Medicare	$4,321.60
Rate for Payer: Humana Medicare	$4,321.60
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$1,900.00
Rate for Payer: Local 1199SEIU Medicare	$4,969.84
Rate for Payer: Multiplan Commercial	$8,643.20
Rate for Payer: MVP Health Care of NY Commercial	$8,103.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$6,082.65
Rate for Payer: MVP Health Care of NY Medicare	$4,537.68
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$1,828.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$1,620.60
Rate for Payer: United Healthcare Commercial	$1,828.00
Rate for Payer: United Healthcare Medicare	$4,321.60
Rate for Payer: WellCare Medicare	$5,942.20

DILAT XST TRC NDURLGC PX

Facility

$10,804.00

Service Code	HCPCS 50436
Hospital Charge Code	4853033
Hospital Revenue Code	761
Min. Negotiated Rate	$1,620.60
Max. Negotiated Rate	$8,643.20
Rate for Payer: Aetna of NY Commercial	$7,562.80
Rate for Payer: Aetna of NY Medicare	$4,969.84
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$4,321.60
Rate for Payer: Cash Price	$8,103.00
Rate for Payer: CDPHP Medicare	$3,997.48
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$8,643.20
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$8,643.20
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$8,643.20
Rate for Payer: EmblemHealth Medicaid	$8,643.20
Rate for Payer: EmblemHealth Medicare	$3,673.36
Rate for Payer: EmblemHealth Select Care	$7,778.88
Rate for Payer: Fidelis Medicare	$4,321.60
Rate for Payer: Galaxy Health Commercial	$7,022.60
Rate for Payer: Hamaspik Choice Medicare	$4,321.60
Rate for Payer: Humana Medicare	$4,321.60
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$7,562.80
Rate for Payer: Local 1199SEIU Medicare	$4,969.84
Rate for Payer: MVP Health Care of NY Commercial	$8,103.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$6,082.65
Rate for Payer: MVP Health Care of NY Medicare	$4,537.68
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$1,620.60
Rate for Payer: United Healthcare Medicare	$4,321.60
Rate for Payer: WellCare Medicare	$5,942.20

DILAT XST TRC NDURLGC PX

Facility

$10,804.00

Service Code	HCPCS 50436
Hospital Charge Code	4853033
Hospital Revenue Code	761
Min. Negotiated Rate	$7,022.60
Max. Negotiated Rate	$7,022.60
Rate for Payer: Cash Price	$8,103.00
Rate for Payer: Galaxy Health Commercial	$7,022.60

DILAT XST TRC NEW ACCESS RCS

Facility

$10,804.00

Service Code	HCPCS 50437
Hospital Charge Code	4853034
Hospital Revenue Code	761
Min. Negotiated Rate	$7,022.60
Max. Negotiated Rate	$7,022.60
Rate for Payer: Cash Price	$8,103.00
Rate for Payer: Galaxy Health Commercial	$7,022.60

DILAT XST TRC NEW ACCESS RCS

Facility

$10,804.00

Service Code	HCPCS 50437
Hospital Charge Code	4853034
Hospital Revenue Code	761
Min. Negotiated Rate	$1,620.60
Max. Negotiated Rate	$8,643.20
Rate for Payer: Aetna of NY Commercial	$7,562.80
Rate for Payer: Aetna of NY Medicare	$4,969.84
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$4,321.60
Rate for Payer: Cash Price	$8,103.00
Rate for Payer: CDPHP Medicare	$3,997.48
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$8,643.20
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$8,643.20
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$8,643.20
Rate for Payer: EmblemHealth Medicaid	$8,643.20
Rate for Payer: EmblemHealth Medicare	$3,673.36
Rate for Payer: EmblemHealth Select Care	$7,778.88
Rate for Payer: Fidelis Medicare	$4,321.60
Rate for Payer: Galaxy Health Commercial	$7,022.60
Rate for Payer: Hamaspik Choice Medicare	$4,321.60
Rate for Payer: Humana Medicare	$4,321.60
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$7,562.80
Rate for Payer: Local 1199SEIU Medicare	$4,969.84
Rate for Payer: MVP Health Care of NY Commercial	$8,103.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$6,082.65
Rate for Payer: MVP Health Care of NY Medicare	$4,537.68
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$1,620.60
Rate for Payer: United Healthcare Medicare	$4,321.60
Rate for Payer: WellCare Medicare	$5,942.20

DILTIAZEM HCL 120MG CAPS 100 EA

Facility

$6.18

Service Code	NDC 63739001410
Hospital Charge Code	4400237
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

DILTIAZEM HCL 120MG CAPS 100 EA

Facility

$6.18

Service Code	NDC 63739001410
Hospital Charge Code	4400237
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

DILTIAZEM HCL 180MG CAPS 100 EA

Facility

$6.18

Service Code	NDC 60687020611
Hospital Charge Code	4400238
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

DILTIAZEM HCL 180MG CAPS 100 EA

Facility

$6.18

Service Code	NDC 60687020611
Hospital Charge Code	4400238
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

DILTIAZEM HCL 30MG TABS 100 EA

Facility

$6.18

Service Code	NDC 63739007910
Hospital Charge Code	4400231
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

DILTIAZEM HCL 30MG TABS 100 EA

Facility

$6.18

Service Code	NDC 63739007910
Hospital Charge Code	4400231
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

DILTIAZEM HCL 5MG/ML SDV 10X10ML

Facility

$6.18

Hospital Charge Code	4400235
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

DILTIAZEM HCL 5MG/ML SDV 10X10ML

Facility

$6.18

Hospital Charge Code	4400235
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

DILTIAZEM HCL 5MG/ML SDV 10X25ML

Facility

$23.35

Service Code	NDC 641601501
Hospital Charge Code	4400233
Hospital Revenue Code	250
Min. Negotiated Rate	$12.84
Max. Negotiated Rate	$15.18
Rate for Payer: Cash Price	$17.51
Rate for Payer: Galaxy Health Commercial	$15.18
Rate for Payer: WellCare Medicare	$12.84

DILTIAZEM HCL 5MG/ML SDV 10X25ML

Facility

$23.35

Service Code	NDC 641601501
Hospital Charge Code	4400233
Hospital Revenue Code	250
Min. Negotiated Rate	$3.50
Max. Negotiated Rate	$18.68
Rate for Payer: Aetna of NY Commercial	$16.34
Rate for Payer: Aetna of NY Medicare	$10.74
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$9.34
Rate for Payer: Cash Price	$17.51
Rate for Payer: CDPHP Medicare	$8.64
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$18.68
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$18.68
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$18.68
Rate for Payer: EmblemHealth Medicaid	$18.68
Rate for Payer: EmblemHealth Medicare	$7.94
Rate for Payer: EmblemHealth Select Care	$16.81
Rate for Payer: Fidelis Medicare	$9.34
Rate for Payer: Galaxy Health Commercial	$15.18
Rate for Payer: Hamaspik Choice Medicare	$9.34
Rate for Payer: Humana Medicare	$9.34
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$16.34
Rate for Payer: Local 1199SEIU Medicare	$10.74
Rate for Payer: MVP Health Care of NY Commercial	$17.51
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$13.15
Rate for Payer: MVP Health Care of NY Medicare	$9.81
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$3.50
Rate for Payer: United Healthcare Medicare	$9.34
Rate for Payer: WellCare Medicare	$12.84

DILTIAZEM HCL 5MG/ML SDV 10X5ML

Facility

$9.00

Service Code	NDC 641601310
Hospital Charge Code	4400232
Hospital Revenue Code	250
Min. Negotiated Rate	$4.95
Max. Negotiated Rate	$5.85
Rate for Payer: Cash Price	$6.75
Rate for Payer: Galaxy Health Commercial	$5.85
Rate for Payer: WellCare Medicare	$4.95

DILTIAZEM HCL 5MG/ML SDV 10X5ML

Facility

$9.00

Service Code	NDC 641601310
Hospital Charge Code	4400232
Hospital Revenue Code	250
Min. Negotiated Rate	$1.35
Max. Negotiated Rate	$7.20
Rate for Payer: Aetna of NY Commercial	$6.30
Rate for Payer: Aetna of NY Medicare	$4.14
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$3.60
Rate for Payer: Cash Price	$6.75
Rate for Payer: CDPHP Medicare	$3.33
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$7.20
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$7.20
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$7.20
Rate for Payer: EmblemHealth Medicaid	$7.20
Rate for Payer: EmblemHealth Medicare	$3.06
Rate for Payer: EmblemHealth Select Care	$6.48
Rate for Payer: Fidelis Medicare	$3.60
Rate for Payer: Galaxy Health Commercial	$5.85
Rate for Payer: Hamaspik Choice Medicare	$3.60
Rate for Payer: Humana Medicare	$3.60
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$6.30
Rate for Payer: Local 1199SEIU Medicare	$4.14
Rate for Payer: MVP Health Care of NY Commercial	$6.75
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$5.07
Rate for Payer: MVP Health Care of NY Medicare	$3.78
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$1.35
Rate for Payer: United Healthcare Medicare	$3.60
Rate for Payer: WellCare Medicare	$4.95

DIPHENHYDRAMINE HCL 12.5MG/5ML LIQD 4 OZ

Facility

$6.18

Service Code	NDC 68094002262
Hospital Charge Code	4400240
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

DIPHENHYDRAMINE HCL 12.5MG/5ML LIQD 4 OZ

Facility

$6.18

Service Code	NDC 68094002262
Hospital Charge Code	4400240
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.

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