Ellenville Regional Hospital

All Charges

Charge

Type

Setting

Price

ELECTROLYTE PANEL

Facility

$21.00

Service Code	HCPCS 80051
Hospital Charge Code	4300294
Hospital Revenue Code	301
Min. Negotiated Rate	$3.15
Max. Negotiated Rate	$16.80
Rate for Payer: Aetna of NY Commercial	$13.65
Rate for Payer: Aetna of NY Medicare	$9.66
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$8.40
Rate for Payer: Cash Price	$15.75
Rate for Payer: CDPHP Medicare	$7.77
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$12.60
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$16.80
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$16.80
Rate for Payer: EmblemHealth Medicaid	$16.80
Rate for Payer: EmblemHealth Medicare	$7.14
Rate for Payer: EmblemHealth Select Care	$12.60
Rate for Payer: Fidelis Medicare	$8.40
Rate for Payer: Galaxy Health Commercial	$13.65
Rate for Payer: Hamaspik Choice Medicare	$8.40
Rate for Payer: Humana Medicare	$8.40
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$13.65
Rate for Payer: Local 1199SEIU Medicare	$9.66
Rate for Payer: MVP Health Care of NY Commercial	$15.75
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$11.82
Rate for Payer: MVP Health Care of NY Medicare	$8.82
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$15.75
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$3.15
Rate for Payer: United Healthcare Commercial	$15.75
Rate for Payer: United Healthcare Medicare	$8.40
Rate for Payer: WellCare Medicare	$11.55

ELECTROLYTE PANEL

Facility

$21.00

Service Code	HCPCS 80051
Hospital Charge Code	4300294
Hospital Revenue Code	301
Min. Negotiated Rate	$13.65
Max. Negotiated Rate	$13.65
Rate for Payer: Cash Price	$15.75
Rate for Payer: Galaxy Health Commercial	$13.65

ELECTROLYTES (URINE)

Facility

$21.00

Service Code	HCPCS 80051
Hospital Charge Code	4300846
Hospital Revenue Code	301
Min. Negotiated Rate	$13.65
Max. Negotiated Rate	$13.65
Rate for Payer: Cash Price	$15.75
Rate for Payer: Galaxy Health Commercial	$13.65

ELECTROLYTES (URINE)

Facility

$21.00

Service Code	HCPCS 80051
Hospital Charge Code	4300846
Hospital Revenue Code	301
Min. Negotiated Rate	$3.15
Max. Negotiated Rate	$16.80
Rate for Payer: Aetna of NY Commercial	$13.65
Rate for Payer: Aetna of NY Medicare	$9.66
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$8.40
Rate for Payer: Cash Price	$15.75
Rate for Payer: CDPHP Medicare	$7.77
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$12.60
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$16.80
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$16.80
Rate for Payer: EmblemHealth Medicaid	$16.80
Rate for Payer: EmblemHealth Medicare	$7.14
Rate for Payer: EmblemHealth Select Care	$12.60
Rate for Payer: Fidelis Medicare	$8.40
Rate for Payer: Galaxy Health Commercial	$13.65
Rate for Payer: Hamaspik Choice Medicare	$8.40
Rate for Payer: Humana Medicare	$8.40
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$13.65
Rate for Payer: Local 1199SEIU Medicare	$9.66
Rate for Payer: MVP Health Care of NY Commercial	$15.75
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$11.82
Rate for Payer: MVP Health Care of NY Medicare	$8.82
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$15.75
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$3.15
Rate for Payer: United Healthcare Commercial	$15.75
Rate for Payer: United Healthcare Medicare	$8.40
Rate for Payer: WellCare Medicare	$11.55

ELECTRONIC ANALYSIS OF PROGRAMMABLE, IMPLANTED PUMP FOR INTRATHECAL OR EPIDURAL DRUG INFUSION (INCLUDES EVALUATION OF RESERVOIR STATUS, ALARM STATUS, DRUG PRESCRIPTION STATUS); WITH REPROGRAMMING

Facility

$1,900.00

Service Code	CPT 62368
Hospital Revenue Code	490
Min. Negotiated Rate	$284.59
Max. Negotiated Rate	$1,900.00
Rate for Payer: Aetna of NY Commercial	$1,900.00
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$1,900.00
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$1,828.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$284.59
Rate for Payer: United Healthcare Commercial	$1,828.00

ELIM PYLORIC/COLONIC

Facility

$398.61

Hospital Charge Code	4471005
Hospital Revenue Code	270
Min. Negotiated Rate	$59.79
Max. Negotiated Rate	$318.89
Rate for Payer: Aetna of NY Commercial	$279.03
Rate for Payer: Aetna of NY Medicare	$183.36
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$159.44
Rate for Payer: Cash Price	$298.96
Rate for Payer: CDPHP Medicare	$147.49
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$318.89
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$318.89
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$318.89
Rate for Payer: EmblemHealth Medicaid	$318.89
Rate for Payer: EmblemHealth Medicare	$135.53
Rate for Payer: EmblemHealth Select Care	$287.00
Rate for Payer: Fidelis Medicare	$159.44
Rate for Payer: Galaxy Health Commercial	$259.10
Rate for Payer: Hamaspik Choice Medicare	$159.44
Rate for Payer: Humana Medicare	$159.44
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$279.03
Rate for Payer: Local 1199SEIU Medicare	$183.36
Rate for Payer: MVP Health Care of NY Commercial	$298.96
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$224.42
Rate for Payer: MVP Health Care of NY Medicare	$167.42
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$59.79
Rate for Payer: United Healthcare Medicare	$159.44
Rate for Payer: WellCare Medicare	$219.24

ELIM PYLORIC/COLONIC

Facility

$398.61

Hospital Charge Code	4471005
Hospital Revenue Code	270
Min. Negotiated Rate	$259.10
Max. Negotiated Rate	$259.10
Rate for Payer: Cash Price	$298.96
Rate for Payer: Galaxy Health Commercial	$259.10

ELIQUIS 2.5 MG TABLET

Facility

$22.15

Service Code	NDC 3089331
Hospital Charge Code	4409209
Hospital Revenue Code	250
Min. Negotiated Rate	$3.32
Max. Negotiated Rate	$17.72
Rate for Payer: Aetna of NY Commercial	$15.51
Rate for Payer: Aetna of NY Medicare	$10.19
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$8.86
Rate for Payer: Cash Price	$16.61
Rate for Payer: CDPHP Medicare	$8.20
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$17.72
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$17.72
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$17.72
Rate for Payer: EmblemHealth Medicaid	$17.72
Rate for Payer: EmblemHealth Medicare	$7.53
Rate for Payer: EmblemHealth Select Care	$15.95
Rate for Payer: Fidelis Medicare	$8.86
Rate for Payer: Galaxy Health Commercial	$14.40
Rate for Payer: Hamaspik Choice Medicare	$8.86
Rate for Payer: Humana Medicare	$8.86
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$15.51
Rate for Payer: Local 1199SEIU Medicare	$10.19
Rate for Payer: MVP Health Care of NY Commercial	$16.61
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$12.47
Rate for Payer: MVP Health Care of NY Medicare	$9.30
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$3.32
Rate for Payer: United Healthcare Medicare	$8.86
Rate for Payer: WellCare Medicare	$12.18

ELIQUIS 2.5 MG TABLET

Facility

$22.15

Service Code	NDC 3089331
Hospital Charge Code	4409209
Hospital Revenue Code	250
Min. Negotiated Rate	$12.18
Max. Negotiated Rate	$14.40
Rate for Payer: Cash Price	$16.61
Rate for Payer: Galaxy Health Commercial	$14.40
Rate for Payer: WellCare Medicare	$12.18

ELIQUIS TAB 5 MG

Facility

$22.15

Service Code	NDC 3089431
Hospital Charge Code	4409202
Hospital Revenue Code	250
Min. Negotiated Rate	$12.18
Max. Negotiated Rate	$14.40
Rate for Payer: Cash Price	$16.61
Rate for Payer: Galaxy Health Commercial	$14.40
Rate for Payer: WellCare Medicare	$12.18

ELIQUIS TAB 5 MG

Facility

$22.15

Service Code	NDC 3089431
Hospital Charge Code	4409202
Hospital Revenue Code	250
Min. Negotiated Rate	$3.32
Max. Negotiated Rate	$17.72
Rate for Payer: Aetna of NY Commercial	$15.51
Rate for Payer: Aetna of NY Medicare	$10.19
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$8.86
Rate for Payer: Cash Price	$16.61
Rate for Payer: CDPHP Medicare	$8.20
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$17.72
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$17.72
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$17.72
Rate for Payer: EmblemHealth Medicaid	$17.72
Rate for Payer: EmblemHealth Medicare	$7.53
Rate for Payer: EmblemHealth Select Care	$15.95
Rate for Payer: Fidelis Medicare	$8.86
Rate for Payer: Galaxy Health Commercial	$14.40
Rate for Payer: Hamaspik Choice Medicare	$8.86
Rate for Payer: Humana Medicare	$8.86
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$15.51
Rate for Payer: Local 1199SEIU Medicare	$10.19
Rate for Payer: MVP Health Care of NY Commercial	$16.61
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$12.47
Rate for Payer: MVP Health Care of NY Medicare	$9.30
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$3.32
Rate for Payer: United Healthcare Medicare	$8.86
Rate for Payer: WellCare Medicare	$12.18

EMERGENCY DEPT VISIT LVL 1

Facility

$275.00

Service Code	HCPCS 99281
Hospital Charge Code	4600082
Hospital Revenue Code	450
Min. Negotiated Rate	$178.75
Max. Negotiated Rate	$178.75
Rate for Payer: Cash Price	$206.25
Rate for Payer: Galaxy Health Commercial	$178.75

EMERGENCY DEPT VISIT LVL 1

Facility

$275.00

Service Code	HCPCS 99281
Hospital Charge Code	4600082
Hospital Revenue Code	450
Min. Negotiated Rate	$41.25
Max. Negotiated Rate	$1,234.00
Rate for Payer: Aetna of NY Commercial	$1,000.00
Rate for Payer: Aetna of NY Medicare	$126.50
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$110.00
Rate for Payer: Cash Price	$206.25
Rate for Payer: Cash Price	$206.25
Rate for Payer: Cash Price	$206.25
Rate for Payer: CDPHP Medicare	$101.75
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$1,206.00
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$220.00
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$220.00
Rate for Payer: EmblemHealth Medicaid	$220.00
Rate for Payer: EmblemHealth Medicare	$93.50
Rate for Payer: EmblemHealth Select Care	$1,085.00
Rate for Payer: Fidelis Medicare	$110.00
Rate for Payer: Galaxy Health Commercial	$178.75
Rate for Payer: Hamaspik Choice Medicare	$110.00
Rate for Payer: Humana Medicare	$110.00
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$1,000.00
Rate for Payer: Local 1199SEIU Medicare	$126.50
Rate for Payer: Multiplan Commercial	$800.00
Rate for Payer: MVP Health Care of NY Commercial	$1,234.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$925.00
Rate for Payer: MVP Health Care of NY Medicare	$115.50
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$1,009.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$41.25
Rate for Payer: United Healthcare Commercial	$1,009.00
Rate for Payer: United Healthcare Medicare	$110.00
Rate for Payer: WellCare Medicare	$151.25

EMERGENCY DEPT VISIT LVL 2

Facility

$587.00

Service Code	HCPCS 99282
Hospital Charge Code	4600083
Hospital Revenue Code	450
Min. Negotiated Rate	$381.55
Max. Negotiated Rate	$381.55
Rate for Payer: Cash Price	$440.25
Rate for Payer: Galaxy Health Commercial	$381.55

EMERGENCY DEPT VISIT LVL 2

Facility

$587.00

Service Code	HCPCS 99282
Hospital Charge Code	4600083
Hospital Revenue Code	450
Min. Negotiated Rate	$88.05
Max. Negotiated Rate	$1,234.00
Rate for Payer: Aetna of NY Commercial	$1,000.00
Rate for Payer: Aetna of NY Medicare	$270.02
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$234.80
Rate for Payer: Cash Price	$440.25
Rate for Payer: Cash Price	$440.25
Rate for Payer: Cash Price	$440.25
Rate for Payer: CDPHP Medicare	$217.19
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$1,206.00
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$469.60
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$469.60
Rate for Payer: EmblemHealth Medicaid	$469.60
Rate for Payer: EmblemHealth Medicare	$199.58
Rate for Payer: EmblemHealth Select Care	$1,085.00
Rate for Payer: Fidelis Medicare	$234.80
Rate for Payer: Galaxy Health Commercial	$381.55
Rate for Payer: Hamaspik Choice Medicare	$234.80
Rate for Payer: Humana Medicare	$234.80
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$1,000.00
Rate for Payer: Local 1199SEIU Medicare	$270.02
Rate for Payer: Multiplan Commercial	$800.00
Rate for Payer: MVP Health Care of NY Commercial	$1,234.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$925.00
Rate for Payer: MVP Health Care of NY Medicare	$246.54
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$1,009.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$88.05
Rate for Payer: United Healthcare Commercial	$1,009.00
Rate for Payer: United Healthcare Medicare	$234.80
Rate for Payer: WellCare Medicare	$322.85

EMERGENCY DEPT VISIT LVL 3

Facility

$899.00

Service Code	HCPCS 99283
Hospital Charge Code	4600084
Hospital Revenue Code	450
Min. Negotiated Rate	$134.85
Max. Negotiated Rate	$1,234.00
Rate for Payer: Aetna of NY Commercial	$1,000.00
Rate for Payer: Aetna of NY Medicare	$413.54
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$359.60
Rate for Payer: Cash Price	$674.25
Rate for Payer: Cash Price	$674.25
Rate for Payer: Cash Price	$674.25
Rate for Payer: CDPHP Medicare	$332.63
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$1,206.00
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$719.20
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$719.20
Rate for Payer: EmblemHealth Medicaid	$719.20
Rate for Payer: EmblemHealth Medicare	$305.66
Rate for Payer: EmblemHealth Select Care	$1,085.00
Rate for Payer: Fidelis Medicare	$359.60
Rate for Payer: Galaxy Health Commercial	$584.35
Rate for Payer: Hamaspik Choice Medicare	$359.60
Rate for Payer: Humana Medicare	$359.60
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$1,000.00
Rate for Payer: Local 1199SEIU Medicare	$413.54
Rate for Payer: Multiplan Commercial	$800.00
Rate for Payer: MVP Health Care of NY Commercial	$1,234.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$925.00
Rate for Payer: MVP Health Care of NY Medicare	$377.58
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$1,009.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$134.85
Rate for Payer: United Healthcare Commercial	$1,009.00
Rate for Payer: United Healthcare Medicare	$359.60
Rate for Payer: WellCare Medicare	$494.45

EMERGENCY DEPT VISIT LVL 3

Facility

$899.00

Service Code	HCPCS 99283
Hospital Charge Code	4600084
Hospital Revenue Code	450
Min. Negotiated Rate	$584.35
Max. Negotiated Rate	$584.35
Rate for Payer: Cash Price	$674.25
Rate for Payer: Galaxy Health Commercial	$584.35

EMERGENCY DEPT VISIT LVL 4

Facility

$1,211.00

Service Code	HCPCS 99284
Hospital Charge Code	4600085
Hospital Revenue Code	450
Min. Negotiated Rate	$787.15
Max. Negotiated Rate	$787.15
Rate for Payer: Cash Price	$908.25
Rate for Payer: Galaxy Health Commercial	$787.15

EMERGENCY DEPT VISIT LVL 4

Facility

$1,211.00

Service Code	HCPCS 99284
Hospital Charge Code	4600085
Hospital Revenue Code	450
Min. Negotiated Rate	$181.65
Max. Negotiated Rate	$1,234.00
Rate for Payer: Aetna of NY Commercial	$1,000.00
Rate for Payer: Aetna of NY Medicare	$557.06
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$484.40
Rate for Payer: Cash Price	$908.25
Rate for Payer: Cash Price	$908.25
Rate for Payer: Cash Price	$908.25
Rate for Payer: CDPHP Medicare	$448.07
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$1,206.00
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$968.80
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$968.80
Rate for Payer: EmblemHealth Medicaid	$968.80
Rate for Payer: EmblemHealth Medicare	$411.74
Rate for Payer: EmblemHealth Select Care	$1,085.00
Rate for Payer: Fidelis Medicare	$484.40
Rate for Payer: Galaxy Health Commercial	$787.15
Rate for Payer: Hamaspik Choice Medicare	$484.40
Rate for Payer: Humana Medicare	$484.40
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$1,000.00
Rate for Payer: Local 1199SEIU Medicare	$557.06
Rate for Payer: Multiplan Commercial	$800.00
Rate for Payer: MVP Health Care of NY Commercial	$1,234.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$925.00
Rate for Payer: MVP Health Care of NY Medicare	$508.62
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$1,009.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$181.65
Rate for Payer: United Healthcare Commercial	$1,009.00
Rate for Payer: United Healthcare Medicare	$484.40
Rate for Payer: WellCare Medicare	$666.05

EMERGENCY DEPT VISIT LVL 5

Facility

$1,523.00

Service Code	HCPCS 99285
Hospital Charge Code	4600086
Hospital Revenue Code	450
Min. Negotiated Rate	$228.45
Max. Negotiated Rate	$1,234.00
Rate for Payer: Aetna of NY Commercial	$1,000.00
Rate for Payer: Aetna of NY Medicare	$700.58
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$609.20
Rate for Payer: Cash Price	$1,142.25
Rate for Payer: Cash Price	$1,142.25
Rate for Payer: Cash Price	$1,142.25
Rate for Payer: CDPHP Medicare	$563.51
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$1,206.00
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$1,218.40
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$1,218.40
Rate for Payer: EmblemHealth Medicaid	$1,218.40
Rate for Payer: EmblemHealth Medicare	$517.82
Rate for Payer: EmblemHealth Select Care	$1,085.00
Rate for Payer: Fidelis Medicare	$609.20
Rate for Payer: Galaxy Health Commercial	$989.95
Rate for Payer: Hamaspik Choice Medicare	$609.20
Rate for Payer: Humana Medicare	$609.20
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$1,000.00
Rate for Payer: Local 1199SEIU Medicare	$700.58
Rate for Payer: Multiplan Commercial	$800.00
Rate for Payer: MVP Health Care of NY Commercial	$1,234.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$925.00
Rate for Payer: MVP Health Care of NY Medicare	$639.66
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$1,009.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$228.45
Rate for Payer: United Healthcare Commercial	$1,009.00
Rate for Payer: United Healthcare Medicare	$609.20
Rate for Payer: WellCare Medicare	$837.65

EMERGENCY DEPT VISIT LVL 5

Facility

$1,523.00

Service Code	HCPCS 99285
Hospital Charge Code	4600086
Hospital Revenue Code	450
Min. Negotiated Rate	$989.95
Max. Negotiated Rate	$989.95
Rate for Payer: Cash Price	$1,142.25
Rate for Payer: Galaxy Health Commercial	$989.95

ENALAPRILAT DIHYDRATE 1.25MG/ML SDV 10X1

Facility

$11.07

Service Code	NDC 143978710
Hospital Charge Code	4400270
Hospital Revenue Code	250
Min. Negotiated Rate	$1.66
Max. Negotiated Rate	$8.86
Rate for Payer: Aetna of NY Commercial	$7.75
Rate for Payer: Aetna of NY Medicare	$5.09
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$4.43
Rate for Payer: Cash Price	$8.30
Rate for Payer: CDPHP Medicare	$4.10
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$8.86
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$8.86
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$8.86
Rate for Payer: EmblemHealth Medicaid	$8.86
Rate for Payer: EmblemHealth Medicare	$3.76
Rate for Payer: EmblemHealth Select Care	$7.97
Rate for Payer: Fidelis Medicare	$4.43
Rate for Payer: Galaxy Health Commercial	$7.20
Rate for Payer: Hamaspik Choice Medicare	$4.43
Rate for Payer: Humana Medicare	$4.43
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$7.75
Rate for Payer: Local 1199SEIU Medicare	$5.09
Rate for Payer: MVP Health Care of NY Commercial	$8.30
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$6.23
Rate for Payer: MVP Health Care of NY Medicare	$4.65
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$1.66
Rate for Payer: United Healthcare Medicare	$4.43
Rate for Payer: WellCare Medicare	$6.09

ENALAPRILAT DIHYDRATE 1.25MG/ML SDV 10X1

Facility

$11.07

Service Code	NDC 143978710
Hospital Charge Code	4400270
Hospital Revenue Code	250
Min. Negotiated Rate	$6.09
Max. Negotiated Rate	$7.20
Rate for Payer: Cash Price	$8.30
Rate for Payer: Galaxy Health Commercial	$7.20
Rate for Payer: WellCare Medicare	$6.09

ENDOSCOPIC CYTOLOGY BRUSH

Facility

$54.59

Hospital Charge Code	4479159
Hospital Revenue Code	270
Min. Negotiated Rate	$35.48
Max. Negotiated Rate	$35.48
Rate for Payer: Cash Price	$40.94
Rate for Payer: Galaxy Health Commercial	$35.48

ENDOSCOPIC CYTOLOGY BRUSH

Facility

$54.59

Hospital Charge Code	4479159
Hospital Revenue Code	270
Min. Negotiated Rate	$8.19
Max. Negotiated Rate	$43.67
Rate for Payer: Aetna of NY Commercial	$38.21
Rate for Payer: Aetna of NY Medicare	$25.11
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$21.84
Rate for Payer: Cash Price	$40.94
Rate for Payer: CDPHP Medicare	$20.20
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$43.67
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$43.67
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$43.67
Rate for Payer: EmblemHealth Medicaid	$43.67
Rate for Payer: EmblemHealth Medicare	$18.56
Rate for Payer: EmblemHealth Select Care	$39.30
Rate for Payer: Fidelis Medicare	$21.84
Rate for Payer: Galaxy Health Commercial	$35.48
Rate for Payer: Hamaspik Choice Medicare	$21.84
Rate for Payer: Humana Medicare	$21.84
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$38.21
Rate for Payer: Local 1199SEIU Medicare	$25.11
Rate for Payer: MVP Health Care of NY Commercial	$40.94
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$30.73
Rate for Payer: MVP Health Care of NY Medicare	$22.93
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$8.19
Rate for Payer: United Healthcare Medicare	$21.84
Rate for Payer: WellCare Medicare	$30.02

Know your out-of-pocket cost for care.

All Charges