Ellenville Regional Hospital

All Charges

Charge

Type

Setting

Price

DOPPLER ECHO; COMPLETE

Facility

$168.00

Service Code	HCPCS 93320
Hospital Charge Code	4480109
Hospital Revenue Code	480
Min. Negotiated Rate	$25.20
Max. Negotiated Rate	$134.40
Rate for Payer: Aetna of NY Commercial	$109.20
Rate for Payer: Aetna of NY Medicare	$77.28
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$67.20
Rate for Payer: Cash Price	$126.00
Rate for Payer: CDPHP Medicare	$62.16
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$117.60
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$134.40
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$134.40
Rate for Payer: EmblemHealth Medicaid	$134.40
Rate for Payer: EmblemHealth Medicare	$57.12
Rate for Payer: EmblemHealth Select Care	$109.20
Rate for Payer: Fidelis Medicare	$67.20
Rate for Payer: Galaxy Health Commercial	$109.20
Rate for Payer: Hamaspik Choice Medicare	$67.20
Rate for Payer: Humana Medicare	$67.20
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$109.20
Rate for Payer: Local 1199SEIU Medicare	$77.28
Rate for Payer: MVP Health Care of NY Commercial	$126.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$94.58
Rate for Payer: MVP Health Care of NY Medicare	$70.56
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$126.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$25.20
Rate for Payer: United Healthcare Commercial	$126.00
Rate for Payer: United Healthcare Medicare	$67.20
Rate for Payer: WellCare Medicare	$92.40

DOPPLER ECHO; COMPLETE

Facility

$168.00

Service Code	HCPCS 93320
Hospital Charge Code	4480109
Hospital Revenue Code	480
Min. Negotiated Rate	$109.20
Max. Negotiated Rate	$109.20
Rate for Payer: Cash Price	$126.00
Rate for Payer: Galaxy Health Commercial	$109.20

DOPPLER ECHO; LIMITED/ F-UP

Facility

$83.00

Service Code	HCPCS 93321
Hospital Charge Code	4480108
Hospital Revenue Code	480
Min. Negotiated Rate	$53.95
Max. Negotiated Rate	$53.95
Rate for Payer: Cash Price	$62.25
Rate for Payer: Galaxy Health Commercial	$53.95

DOPPLER ECHO; LIMITED/ F-UP

Facility

$83.00

Service Code	HCPCS 93321
Hospital Charge Code	4480108
Hospital Revenue Code	480
Min. Negotiated Rate	$12.45
Max. Negotiated Rate	$66.40
Rate for Payer: Aetna of NY Commercial	$53.95
Rate for Payer: Aetna of NY Medicare	$38.18
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$33.20
Rate for Payer: Cash Price	$62.25
Rate for Payer: CDPHP Medicare	$30.71
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$58.10
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$66.40
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$66.40
Rate for Payer: EmblemHealth Medicaid	$66.40
Rate for Payer: EmblemHealth Medicare	$28.22
Rate for Payer: EmblemHealth Select Care	$53.95
Rate for Payer: Fidelis Medicare	$33.20
Rate for Payer: Galaxy Health Commercial	$53.95
Rate for Payer: Hamaspik Choice Medicare	$33.20
Rate for Payer: Humana Medicare	$33.20
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$53.95
Rate for Payer: Local 1199SEIU Medicare	$38.18
Rate for Payer: MVP Health Care of NY Commercial	$62.25
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$46.73
Rate for Payer: MVP Health Care of NY Medicare	$34.86
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$62.25
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$12.45
Rate for Payer: United Healthcare Commercial	$62.25
Rate for Payer: United Healthcare Medicare	$33.20
Rate for Payer: WellCare Medicare	$45.65

DORSAL PF NIGHT SPLINT LARGE

Facility

$138.02

Hospital Charge Code	4471460
Hospital Revenue Code	270
Min. Negotiated Rate	$89.71
Max. Negotiated Rate	$89.71
Rate for Payer: Cash Price	$103.52
Rate for Payer: Galaxy Health Commercial	$89.71

DORSAL PF NIGHT SPLINT LARGE

Facility

$138.02

Hospital Charge Code	4471460
Hospital Revenue Code	270
Min. Negotiated Rate	$20.70
Max. Negotiated Rate	$110.42
Rate for Payer: Aetna of NY Commercial	$96.61
Rate for Payer: Aetna of NY Medicare	$63.49
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$55.21
Rate for Payer: Cash Price	$103.52
Rate for Payer: CDPHP Medicare	$51.07
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$110.42
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$110.42
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$110.42
Rate for Payer: EmblemHealth Medicaid	$110.42
Rate for Payer: EmblemHealth Medicare	$46.93
Rate for Payer: EmblemHealth Select Care	$99.37
Rate for Payer: Fidelis Medicare	$55.21
Rate for Payer: Galaxy Health Commercial	$89.71
Rate for Payer: Hamaspik Choice Medicare	$55.21
Rate for Payer: Humana Medicare	$55.21
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$96.61
Rate for Payer: Local 1199SEIU Medicare	$63.49
Rate for Payer: MVP Health Care of NY Commercial	$103.52
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$77.71
Rate for Payer: MVP Health Care of NY Medicare	$57.97
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$20.70
Rate for Payer: United Healthcare Medicare	$55.21
Rate for Payer: WellCare Medicare	$75.91

DORSAL PF NIGHT SPLINT MED

Facility

$138.02

Hospital Charge Code	4471459
Hospital Revenue Code	270
Min. Negotiated Rate	$89.71
Max. Negotiated Rate	$89.71
Rate for Payer: Cash Price	$103.52
Rate for Payer: Galaxy Health Commercial	$89.71

DORSAL PF NIGHT SPLINT MED

Facility

$138.02

Hospital Charge Code	4471459
Hospital Revenue Code	270
Min. Negotiated Rate	$20.70
Max. Negotiated Rate	$110.42
Rate for Payer: Aetna of NY Commercial	$96.61
Rate for Payer: Aetna of NY Medicare	$63.49
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$55.21
Rate for Payer: Cash Price	$103.52
Rate for Payer: CDPHP Medicare	$51.07
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$110.42
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$110.42
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$110.42
Rate for Payer: EmblemHealth Medicaid	$110.42
Rate for Payer: EmblemHealth Medicare	$46.93
Rate for Payer: EmblemHealth Select Care	$99.37
Rate for Payer: Fidelis Medicare	$55.21
Rate for Payer: Galaxy Health Commercial	$89.71
Rate for Payer: Hamaspik Choice Medicare	$55.21
Rate for Payer: Humana Medicare	$55.21
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$96.61
Rate for Payer: Local 1199SEIU Medicare	$63.49
Rate for Payer: MVP Health Care of NY Commercial	$103.52
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$77.71
Rate for Payer: MVP Health Care of NY Medicare	$57.97
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$20.70
Rate for Payer: United Healthcare Medicare	$55.21
Rate for Payer: WellCare Medicare	$75.91

DORZOLAMIDE HCL 2% EYE DROPS 10 mL, 10 mL

Facility

$200.00

Service Code	NDC 61314001910
Hospital Charge Code	4401334
Hospital Revenue Code	250
Min. Negotiated Rate	$110.00
Max. Negotiated Rate	$130.00
Rate for Payer: Cash Price	$150.00
Rate for Payer: Galaxy Health Commercial	$130.00
Rate for Payer: WellCare Medicare	$110.00

DORZOLAMIDE HCL 2% EYE DROPS 10 mL, 10 mL

Facility

$200.00

Service Code	NDC 61314001910
Hospital Charge Code	4401334
Hospital Revenue Code	250
Min. Negotiated Rate	$30.00
Max. Negotiated Rate	$160.00
Rate for Payer: Aetna of NY Commercial	$140.00
Rate for Payer: Aetna of NY Medicare	$92.00
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$80.00
Rate for Payer: Cash Price	$150.00
Rate for Payer: CDPHP Medicare	$74.00
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$160.00
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$160.00
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$160.00
Rate for Payer: EmblemHealth Medicaid	$160.00
Rate for Payer: EmblemHealth Medicare	$68.00
Rate for Payer: EmblemHealth Select Care	$144.00
Rate for Payer: Fidelis Medicare	$80.00
Rate for Payer: Galaxy Health Commercial	$130.00
Rate for Payer: Hamaspik Choice Medicare	$80.00
Rate for Payer: Humana Medicare	$80.00
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$140.00
Rate for Payer: Local 1199SEIU Medicare	$92.00
Rate for Payer: MVP Health Care of NY Commercial	$150.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$112.60
Rate for Payer: MVP Health Care of NY Medicare	$84.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$30.00
Rate for Payer: United Healthcare Medicare	$80.00
Rate for Payer: WellCare Medicare	$110.00

DORZOLAMIDE/TIMOLOL 2-0.5% DROP 10 ML

Facility

$208.58

Service Code	NDC 24208048610
Hospital Charge Code	4400255
Hospital Revenue Code	250
Min. Negotiated Rate	$114.72
Max. Negotiated Rate	$135.58
Rate for Payer: Cash Price	$156.44
Rate for Payer: Galaxy Health Commercial	$135.58
Rate for Payer: WellCare Medicare	$114.72

DORZOLAMIDE/TIMOLOL 2-0.5% DROP 10 ML

Facility

$208.58

Service Code	NDC 24208048610
Hospital Charge Code	4400255
Hospital Revenue Code	250
Min. Negotiated Rate	$31.29
Max. Negotiated Rate	$166.86
Rate for Payer: Aetna of NY Commercial	$146.01
Rate for Payer: Aetna of NY Medicare	$95.95
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$83.43
Rate for Payer: Cash Price	$156.44
Rate for Payer: CDPHP Medicare	$77.17
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$166.86
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$166.86
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$166.86
Rate for Payer: EmblemHealth Medicaid	$166.86
Rate for Payer: EmblemHealth Medicare	$70.92
Rate for Payer: EmblemHealth Select Care	$150.18
Rate for Payer: Fidelis Medicare	$83.43
Rate for Payer: Galaxy Health Commercial	$135.58
Rate for Payer: Hamaspik Choice Medicare	$83.43
Rate for Payer: Humana Medicare	$83.43
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$146.01
Rate for Payer: Local 1199SEIU Medicare	$95.95
Rate for Payer: MVP Health Care of NY Commercial	$156.44
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$117.43
Rate for Payer: MVP Health Care of NY Medicare	$87.60
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$31.29
Rate for Payer: United Healthcare Medicare	$83.43
Rate for Payer: WellCare Medicare	$114.72

DOXAPRAM HCL 20MG/ML MDV 6X20ML

Facility

$7.73

Service Code	HCPCS J3490
Hospital Charge Code	4400254
Hospital Revenue Code	636
Min. Negotiated Rate	$4.25
Max. Negotiated Rate	$5.02
Rate for Payer: Aetna of NY Commercial	$4.25
Rate for Payer: Cash Price	$5.80
Rate for Payer: Galaxy Health Commercial	$5.02
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$4.25
Rate for Payer: WellCare Medicare	$4.25

DOXAPRAM HCL 20MG/ML MDV 6X20ML

Facility

$7.73

Service Code	HCPCS J3490
Hospital Charge Code	4400254
Hospital Revenue Code	636
Min. Negotiated Rate	$1.16
Max. Negotiated Rate	$6.18
Rate for Payer: Aetna of NY Medicare	$3.56
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$3.09
Rate for Payer: Cash Price	$5.80
Rate for Payer: CDPHP Medicare	$2.86
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$6.18
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$6.18
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$6.18
Rate for Payer: EmblemHealth Medicaid	$6.18
Rate for Payer: EmblemHealth Medicare	$2.63
Rate for Payer: EmblemHealth Select Care	$5.57
Rate for Payer: Fidelis Medicare	$3.09
Rate for Payer: Galaxy Health Commercial	$5.02
Rate for Payer: Hamaspik Choice Medicare	$3.09
Rate for Payer: Humana Medicare	$3.09
Rate for Payer: Local 1199SEIU Medicare	$3.56
Rate for Payer: MVP Health Care of NY Commercial	$5.80
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$4.35
Rate for Payer: MVP Health Care of NY Medicare	$3.25
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$1.16
Rate for Payer: United Healthcare Medicare	$3.09
Rate for Payer: WellCare Medicare	$4.25

DOXAZOSIN MESYLATE 2MG TABS 100 EA

Facility

$11.59

Service Code	NDC 51079095820
Hospital Charge Code	4400256
Hospital Revenue Code	250
Min. Negotiated Rate	$1.74
Max. Negotiated Rate	$9.27
Rate for Payer: Aetna of NY Commercial	$8.11
Rate for Payer: Aetna of NY Medicare	$5.33
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$4.64
Rate for Payer: Cash Price	$8.69
Rate for Payer: CDPHP Medicare	$4.29
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$9.27
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$9.27
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$9.27
Rate for Payer: EmblemHealth Medicaid	$9.27
Rate for Payer: EmblemHealth Medicare	$3.94
Rate for Payer: EmblemHealth Select Care	$8.34
Rate for Payer: Fidelis Medicare	$4.64
Rate for Payer: Galaxy Health Commercial	$7.53
Rate for Payer: Hamaspik Choice Medicare	$4.64
Rate for Payer: Humana Medicare	$4.64
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$8.11
Rate for Payer: Local 1199SEIU Medicare	$5.33
Rate for Payer: MVP Health Care of NY Commercial	$8.69
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$6.53
Rate for Payer: MVP Health Care of NY Medicare	$4.87
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$1.74
Rate for Payer: United Healthcare Medicare	$4.64
Rate for Payer: WellCare Medicare	$6.37

DOXAZOSIN MESYLATE 2MG TABS 100 EA

Facility

$11.59

Service Code	NDC 51079095820
Hospital Charge Code	4400256
Hospital Revenue Code	250
Min. Negotiated Rate	$6.37
Max. Negotiated Rate	$7.53
Rate for Payer: Cash Price	$8.69
Rate for Payer: Galaxy Health Commercial	$7.53
Rate for Payer: WellCare Medicare	$6.37

DOXEPIN 25 MG CAPSULE 25 mg, 100 eaches

Facility

$6.00

Service Code	NDC 51079043720
Hospital Charge Code	4401308
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

DOXEPIN 25 MG CAPSULE 25 mg, 100 eaches

Facility

$6.00

Service Code	NDC 51079043720
Hospital Charge Code	4401308
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

DOXEPIN 50 MG CAPSULES

Facility

$6.18

Service Code	NDC 51079043820
Hospital Charge Code	4409085
Hospital Revenue Code	270
Min. Negotiated Rate	$4.02
Max. Negotiated Rate	$4.02
Rate for Payer: Cash Price	$4.64
Rate for Payer: Galaxy Health Commercial	$4.02

DOXEPIN 50 MG CAPSULES

Facility

$6.18

Service Code	NDC 51079043820
Hospital Charge Code	4409085
Hospital Revenue Code	270
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

DOXYCYCLINE 100 MG

Facility

$18.00

Service Code	NDC 60687011811
Hospital Charge Code	4409125
Hospital Revenue Code	250
Min. Negotiated Rate	$2.70
Max. Negotiated Rate	$14.40
Rate for Payer: Aetna of NY Commercial	$12.60
Rate for Payer: Aetna of NY Medicare	$8.28
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$7.20
Rate for Payer: Cash Price	$13.50
Rate for Payer: CDPHP Medicare	$6.66
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$14.40
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$14.40
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$14.40
Rate for Payer: EmblemHealth Medicaid	$14.40
Rate for Payer: EmblemHealth Medicare	$6.12
Rate for Payer: EmblemHealth Select Care	$12.96
Rate for Payer: Fidelis Medicare	$7.20
Rate for Payer: Galaxy Health Commercial	$11.70
Rate for Payer: Hamaspik Choice Medicare	$7.20
Rate for Payer: Humana Medicare	$7.20
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$12.60
Rate for Payer: Local 1199SEIU Medicare	$8.28
Rate for Payer: MVP Health Care of NY Commercial	$13.50
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$10.13
Rate for Payer: MVP Health Care of NY Medicare	$7.56
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$2.70
Rate for Payer: United Healthcare Medicare	$7.20
Rate for Payer: WellCare Medicare	$9.90

DOXYCYCLINE 100 MG

Facility

$18.00

Service Code	NDC 60687011811
Hospital Charge Code	4409125
Hospital Revenue Code	250
Min. Negotiated Rate	$9.90
Max. Negotiated Rate	$11.70
Rate for Payer: Cash Price	$13.50
Rate for Payer: Galaxy Health Commercial	$11.70
Rate for Payer: WellCare Medicare	$9.90

DOXYCYCLINE HYCLATE 100MG PWVL 10X1EA

Facility

$56.14

Service Code	NDC 63323013011
Hospital Charge Code	4400258
Hospital Revenue Code	250
Min. Negotiated Rate	$8.42
Max. Negotiated Rate	$44.91
Rate for Payer: Aetna of NY Commercial	$39.30
Rate for Payer: Aetna of NY Medicare	$25.82
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$22.46
Rate for Payer: Cash Price	$42.10
Rate for Payer: CDPHP Medicare	$20.77
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$44.91
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$44.91
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$44.91
Rate for Payer: EmblemHealth Medicaid	$44.91
Rate for Payer: EmblemHealth Medicare	$19.09
Rate for Payer: EmblemHealth Select Care	$40.42
Rate for Payer: Fidelis Medicare	$22.46
Rate for Payer: Galaxy Health Commercial	$36.49
Rate for Payer: Hamaspik Choice Medicare	$22.46
Rate for Payer: Humana Medicare	$22.46
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$39.30
Rate for Payer: Local 1199SEIU Medicare	$25.82
Rate for Payer: MVP Health Care of NY Commercial	$42.10
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$31.61
Rate for Payer: MVP Health Care of NY Medicare	$23.58
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$8.42
Rate for Payer: United Healthcare Medicare	$22.46
Rate for Payer: WellCare Medicare	$30.88

DOXYCYCLINE HYCLATE 100MG PWVL 10X1EA

Facility

$56.14

Service Code	NDC 63323013011
Hospital Charge Code	4400258
Hospital Revenue Code	250
Min. Negotiated Rate	$30.88
Max. Negotiated Rate	$36.49
Rate for Payer: Cash Price	$42.10
Rate for Payer: Galaxy Health Commercial	$36.49
Rate for Payer: WellCare Medicare	$30.88

DOXYCYCLINE HYCLATE 100MG TABS 10X10EA

Facility

$6.18

Hospital Charge Code	4400259
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

Know your out-of-pocket cost for care.

All Charges