Ellenville Regional Hospital

All Charges

Charge

Type

Setting

Price

DISPOSIBLE SCLEROTHERAPY NEEDL

Facility

$110.21

Hospital Charge Code	4471000
Hospital Revenue Code	270
Min. Negotiated Rate	$16.53
Max. Negotiated Rate	$88.17
Rate for Payer: Aetna of NY Commercial	$77.15
Rate for Payer: Aetna of NY Medicare	$50.70
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$44.08
Rate for Payer: Cash Price	$82.66
Rate for Payer: CDPHP Medicare	$40.78
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$88.17
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$88.17
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$88.17
Rate for Payer: EmblemHealth Medicaid	$88.17
Rate for Payer: EmblemHealth Medicare	$37.47
Rate for Payer: EmblemHealth Select Care	$79.35
Rate for Payer: Fidelis Medicare	$44.08
Rate for Payer: Galaxy Health Commercial	$71.64
Rate for Payer: Hamaspik Choice Medicare	$44.08
Rate for Payer: Humana Medicare	$44.08
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$77.15
Rate for Payer: Local 1199SEIU Medicare	$50.70
Rate for Payer: MVP Health Care of NY Commercial	$82.66
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$62.05
Rate for Payer: MVP Health Care of NY Medicare	$46.29
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$16.53
Rate for Payer: United Healthcare Medicare	$44.08
Rate for Payer: WellCare Medicare	$60.62

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	$0.15
Max. Negotiated Rate	$0.80
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) Medicare	$0.40
Rate for Payer: Cash Price	$0.75
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	$0.40
Rate for Payer: Galaxy Health Commercial	$0.65
Rate for Payer: Hamaspik Choice Medicare	$0.40
Rate for Payer: Humana Medicare	$0.40
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	$0.42
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$0.15
Rate for Payer: United Healthcare Medicare	$0.40
Rate for Payer: WellCare Medicare	$0.55

DIVALPROEX SOD ER 250 MG TAB 250 mg, 100 eaches

Facility

$6.00

Service Code	NDC 904636361
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

DIVALPROEX SOD ER 250 MG TAB 250 mg, 100 eaches

Facility

$6.00

Service Code	NDC 904636361
Hospital Charge Code	4401365
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

DNA/RNA; MULTI ORG - AMP PR

Facility

$246.00

Service Code	HCPCS 87801
Hospital Charge Code	4302007
Hospital Revenue Code	300
Min. Negotiated Rate	$36.90
Max. Negotiated Rate	$196.80
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) Medicare	$98.40
Rate for Payer: Cash Price	$184.50
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	$98.40
Rate for Payer: Galaxy Health Commercial	$159.90
Rate for Payer: Hamaspik Choice Medicare	$98.40
Rate for Payer: Humana Medicare	$98.40
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	$103.32
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$184.50
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$36.90
Rate for Payer: United Healthcare Commercial	$184.50
Rate for Payer: United Healthcare Medicare	$98.40
Rate for Payer: WellCare Medicare	$135.30

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

DOBUTAMINE 5%DEXTROSE 250MG

Facility

$7.21

Hospital Charge Code	4471209
Hospital Revenue Code	270
Min. Negotiated Rate	$4.69
Max. Negotiated Rate	$4.69
Rate for Payer: Cash Price	$5.41
Rate for Payer: Galaxy Health Commercial	$4.69

DOBUTAMINE 5%DEXTROSE 250MG

Facility

$7.21

Hospital Charge Code	4471209
Hospital Revenue Code	270
Min. Negotiated Rate	$1.08
Max. Negotiated Rate	$5.77
Rate for Payer: Aetna of NY Commercial	$5.05
Rate for Payer: Aetna of NY Medicare	$3.32
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$2.88
Rate for Payer: Cash Price	$5.41
Rate for Payer: CDPHP Medicare	$2.67
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$5.77
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$5.77
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$5.77
Rate for Payer: EmblemHealth Medicaid	$5.77
Rate for Payer: EmblemHealth Medicare	$2.45
Rate for Payer: EmblemHealth Select Care	$5.19
Rate for Payer: Fidelis Medicare	$2.88
Rate for Payer: Galaxy Health Commercial	$4.69
Rate for Payer: Hamaspik Choice Medicare	$2.88
Rate for Payer: Humana Medicare	$2.88
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$5.05
Rate for Payer: Local 1199SEIU Medicare	$3.32
Rate for Payer: MVP Health Care of NY Commercial	$5.41
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$4.06
Rate for Payer: MVP Health Care of NY Medicare	$3.03
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$1.08
Rate for Payer: United Healthcare Medicare	$2.88
Rate for Payer: WellCare Medicare	$3.97

DOBUTAMINE HYDROCHLORIDE INJ, PER 250 MG

Facility

$61.03

Service Code	HCPCS J1250
Hospital Charge Code	4450003
Hospital Revenue Code	636
Min. Negotiated Rate	$7.88
Max. Negotiated Rate	$39.67
Rate for Payer: Aetna of NY Commercial	$33.57
Rate for Payer: Cash Price	$45.77
Rate for Payer: Cash Price	$45.77
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$7.88
Rate for Payer: EmblemHealth Select Care	$7.88
Rate for Payer: Galaxy Health Commercial	$39.67
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$33.57
Rate for Payer: WellCare Medicare	$33.57

DOBUTAMINE HYDROCHLORIDE INJ, PER 250 MG

Facility

$17.25

Service Code	HCPCS J1250
Hospital Charge Code	4400248
Hospital Revenue Code	636
Min. Negotiated Rate	$7.88
Max. Negotiated Rate	$11.21
Rate for Payer: Aetna of NY Commercial	$9.49
Rate for Payer: Cash Price	$12.94
Rate for Payer: Cash Price	$12.94
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$7.88
Rate for Payer: EmblemHealth Select Care	$7.88
Rate for Payer: Galaxy Health Commercial	$11.21
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$9.49
Rate for Payer: WellCare Medicare	$9.49

DOBUTAMINE HYDROCHLORIDE INJ, PER 250 MG

Facility

$61.03

Service Code	HCPCS J1250
Hospital Charge Code	4450003
Hospital Revenue Code	636
Min. Negotiated Rate	$7.88
Max. Negotiated Rate	$48.82
Rate for Payer: Aetna of NY Medicare	$28.07
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$24.41
Rate for Payer: Cash Price	$45.77
Rate for Payer: Cash Price	$45.77
Rate for Payer: CDPHP Medicare	$22.58
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$7.88
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$48.82
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$48.82
Rate for Payer: EmblemHealth Medicaid	$48.82
Rate for Payer: EmblemHealth Medicare	$20.75
Rate for Payer: EmblemHealth Select Care	$7.88
Rate for Payer: Fidelis Medicare	$24.41
Rate for Payer: Galaxy Health Commercial	$39.67
Rate for Payer: Hamaspik Choice Medicare	$24.41
Rate for Payer: Humana Medicare	$24.41
Rate for Payer: Local 1199SEIU Medicare	$28.07
Rate for Payer: MVP Health Care of NY Commercial	$45.77
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$34.36
Rate for Payer: MVP Health Care of NY Medicare	$25.63
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$14.57
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$9.15
Rate for Payer: United Healthcare Commercial	$14.57
Rate for Payer: United Healthcare Medicare	$24.41
Rate for Payer: WellCare Medicare	$33.57

DOBUTAMINE HYDROCHLORIDE INJ, PER 250 MG

Facility

$17.25

Service Code	HCPCS J1250
Hospital Charge Code	4400248
Hospital Revenue Code	636
Min. Negotiated Rate	$2.59
Max. Negotiated Rate	$14.57
Rate for Payer: Aetna of NY Medicare	$7.93
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$6.90
Rate for Payer: Cash Price	$12.94
Rate for Payer: Cash Price	$12.94
Rate for Payer: CDPHP Medicare	$6.38
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$7.88
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$13.80
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$13.80
Rate for Payer: EmblemHealth Medicaid	$13.80
Rate for Payer: EmblemHealth Medicare	$5.87
Rate for Payer: EmblemHealth Select Care	$7.88
Rate for Payer: Fidelis Medicare	$6.90
Rate for Payer: Galaxy Health Commercial	$11.21
Rate for Payer: Hamaspik Choice Medicare	$6.90
Rate for Payer: Humana Medicare	$6.90
Rate for Payer: Local 1199SEIU Medicare	$7.93
Rate for Payer: MVP Health Care of NY Commercial	$12.94
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$9.71
Rate for Payer: MVP Health Care of NY Medicare	$7.25
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$14.57
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$2.59
Rate for Payer: United Healthcare Commercial	$14.57
Rate for Payer: United Healthcare Medicare	$6.90
Rate for Payer: WellCare Medicare	$9.49

DOCU LIQUID 100 MG/10 ML 100 mg, 10 mL

Facility

$6.00

Service Code	NDC 50383077111
Hospital Charge Code	4401351
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

DOCU LIQUID 100 MG/10 ML 100 mg, 10 mL

Facility

$6.00

Service Code	NDC 50383077111
Hospital Charge Code	4401351
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

DOCUSATE 100 MG CAP

Facility

$6.18

Service Code	NDC 904645561
Hospital Charge Code	4401262
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

DOCUSATE 100 MG CAP

Facility

$6.18

Service Code	NDC 904645561
Hospital Charge Code	4401262
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

DONEPEZIL HCL 5 MG TABLET 5 mcg, 100 eaches

Facility

$6.00

Service Code	NDC 904647761
Hospital Charge Code	4401518
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

DONEPEZIL HCL 5 MG TABLET 5 mcg, 100 eaches

Facility

$6.00

Service Code	NDC 904647761
Hospital Charge Code	4401518
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

DONEPEZIL HCL 5MG TABS 10X10EA

Facility

$6.18

Service Code	NDC 904624261
Hospital Charge Code	4400068
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

DONEPEZIL HCL 5MG TABS 10X10EA

Facility

$6.18

Service Code	NDC 904624261
Hospital Charge Code	4400068
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

DONNATAL ELIXIR 5 mL, 5 mL

Facility

$126.00

Service Code	NDC 66689006301
Hospital Charge Code	4401323
Hospital Revenue Code	250
Min. Negotiated Rate	$18.90
Max. Negotiated Rate	$100.80
Rate for Payer: Aetna of NY Commercial	$88.20
Rate for Payer: Aetna of NY Medicare	$57.96
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$50.40
Rate for Payer: Cash Price	$94.50
Rate for Payer: CDPHP Medicare	$46.62
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$100.80
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$100.80
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$100.80
Rate for Payer: EmblemHealth Medicaid	$100.80
Rate for Payer: EmblemHealth Medicare	$42.84
Rate for Payer: EmblemHealth Select Care	$90.72
Rate for Payer: Fidelis Medicare	$50.40
Rate for Payer: Galaxy Health Commercial	$81.90
Rate for Payer: Hamaspik Choice Medicare	$50.40
Rate for Payer: Humana Medicare	$50.40
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$88.20
Rate for Payer: Local 1199SEIU Medicare	$57.96
Rate for Payer: MVP Health Care of NY Commercial	$94.50
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$70.94
Rate for Payer: MVP Health Care of NY Medicare	$52.92
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$18.90
Rate for Payer: United Healthcare Medicare	$50.40
Rate for Payer: WellCare Medicare	$69.30

DONNATAL ELIXIR 5 mL, 5 mL

Facility

$126.00

Service Code	NDC 66689006301
Hospital Charge Code	4401323
Hospital Revenue Code	250
Min. Negotiated Rate	$69.30
Max. Negotiated Rate	$81.90
Rate for Payer: Cash Price	$94.50
Rate for Payer: Galaxy Health Commercial	$81.90
Rate for Payer: WellCare Medicare	$69.30

DOPAMINE INJECTION 40 MG

Facility

$33.22

Service Code	HCPCS J1265
Hospital Charge Code	4450004
Hospital Revenue Code	636
Min. Negotiated Rate	$0.80
Max. Negotiated Rate	$26.58
Rate for Payer: Aetna of NY Medicare	$15.28
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$13.29
Rate for Payer: Cash Price	$24.92
Rate for Payer: Cash Price	$24.92
Rate for Payer: CDPHP Medicare	$12.29
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$0.80
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$26.58
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$26.58
Rate for Payer: EmblemHealth Medicaid	$26.58
Rate for Payer: EmblemHealth Medicare	$11.29
Rate for Payer: EmblemHealth Select Care	$0.80
Rate for Payer: Fidelis Medicare	$13.29
Rate for Payer: Galaxy Health Commercial	$21.59
Rate for Payer: Hamaspik Choice Medicare	$13.29
Rate for Payer: Humana Medicare	$13.29
Rate for Payer: Local 1199SEIU Medicare	$15.28
Rate for Payer: MVP Health Care of NY Commercial	$24.91
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$18.70
Rate for Payer: MVP Health Care of NY Medicare	$13.95
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$1.16
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$4.98
Rate for Payer: United Healthcare Commercial	$1.16
Rate for Payer: United Healthcare Medicare	$13.29
Rate for Payer: WellCare Medicare	$18.27

DOPAMINE INJECTION 40 MG

Facility

$33.22

Service Code	HCPCS J1265
Hospital Charge Code	4450004
Hospital Revenue Code	636
Min. Negotiated Rate	$0.80
Max. Negotiated Rate	$21.59
Rate for Payer: Aetna of NY Commercial	$18.27
Rate for Payer: Cash Price	$24.92
Rate for Payer: Cash Price	$24.92
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$0.80
Rate for Payer: EmblemHealth Select Care	$0.80
Rate for Payer: Galaxy Health Commercial	$21.59
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$18.27
Rate for Payer: WellCare Medicare	$18.27

Know your out-of-pocket cost for care.

All Charges