Ellenville Regional Hospital

All Charges

Charge

Type

Setting

Price

EXC URETHRAL DIVERTICULUM SPX FEMALE

Facility

$16,434.00

Service Code	HCPCS 53230
Hospital Charge Code	4002034
Hospital Revenue Code	490
Min. Negotiated Rate	$10,682.10
Max. Negotiated Rate	$10,682.10
Rate for Payer: Cash Price	$12,325.50
Rate for Payer: Galaxy Health Commercial	$10,682.10

EXC VARICOCELE/LIGATION SPERMATIC VEINS SPX

Facility

$10,804.00

Service Code	HCPCS 55530
Hospital Charge Code	4002063
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	$2,097.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$1,620.60
Rate for Payer: United Healthcare Commercial	$2,097.00
Rate for Payer: United Healthcare Medicare	$4,321.60
Rate for Payer: WellCare Medicare	$5,942.20

EXC VARICOCELE/LIGATION SPERMATIC VEINS SPX

Facility

$10,804.00

Service Code	HCPCS 55530
Hospital Charge Code	4002063
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

EXERCISE TST BRNCSPSM

Facility

$408.00

Service Code	HCPCS 94617
Hospital Charge Code	4530013
Hospital Revenue Code	460
Min. Negotiated Rate	$265.20
Max. Negotiated Rate	$265.20
Rate for Payer: Cash Price	$306.00
Rate for Payer: Galaxy Health Commercial	$265.20

EXERCISE TST BRNCSPSM

Facility

$408.00

Service Code	HCPCS 94617
Hospital Charge Code	4530013
Hospital Revenue Code	460
Min. Negotiated Rate	$61.20
Max. Negotiated Rate	$326.40
Rate for Payer: Aetna of NY Commercial	$285.60
Rate for Payer: Aetna of NY Medicare	$187.68
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$163.20
Rate for Payer: Cash Price	$306.00
Rate for Payer: CDPHP Medicare	$150.96
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$285.60
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$326.40
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$326.40
Rate for Payer: EmblemHealth Medicaid	$326.40
Rate for Payer: EmblemHealth Medicare	$138.72
Rate for Payer: EmblemHealth Select Care	$265.20
Rate for Payer: Fidelis Medicare	$163.20
Rate for Payer: Galaxy Health Commercial	$265.20
Rate for Payer: Hamaspik Choice Medicare	$163.20
Rate for Payer: Humana Medicare	$163.20
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$285.60
Rate for Payer: Local 1199SEIU Medicare	$187.68
Rate for Payer: MVP Health Care of NY Commercial	$306.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$229.70
Rate for Payer: MVP Health Care of NY Medicare	$171.36
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$61.20
Rate for Payer: United Healthcare Medicare	$163.20
Rate for Payer: WellCare Medicare	$224.40

EXPRESS CURETTE

Facility

$1,752.03

Hospital Charge Code	4478252
Hospital Revenue Code	272
Min. Negotiated Rate	$1,138.82
Max. Negotiated Rate	$1,138.82
Rate for Payer: Cash Price	$1,314.02
Rate for Payer: Galaxy Health Commercial	$1,138.82

EXPRESS CURETTE

Facility

$1,752.03

Hospital Charge Code	4478252
Hospital Revenue Code	272
Min. Negotiated Rate	$262.80
Max. Negotiated Rate	$1,401.62
Rate for Payer: Aetna of NY Commercial	$1,226.42
Rate for Payer: Aetna of NY Medicare	$805.93
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$700.81
Rate for Payer: Cash Price	$1,314.02
Rate for Payer: CDPHP Medicare	$648.25
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$1,401.62
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$1,401.62
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$1,401.62
Rate for Payer: EmblemHealth Medicaid	$1,401.62
Rate for Payer: EmblemHealth Medicare	$595.69
Rate for Payer: EmblemHealth Select Care	$1,261.46
Rate for Payer: Fidelis Medicare	$700.81
Rate for Payer: Galaxy Health Commercial	$1,138.82
Rate for Payer: Hamaspik Choice Medicare	$700.81
Rate for Payer: Humana Medicare	$700.81
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$1,226.42
Rate for Payer: Local 1199SEIU Medicare	$805.93
Rate for Payer: MVP Health Care of NY Commercial	$1,314.02
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$986.39
Rate for Payer: MVP Health Care of NY Medicare	$735.85
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$262.80
Rate for Payer: United Healthcare Medicare	$700.81
Rate for Payer: WellCare Medicare	$963.62

EXTERNAL ECG SCANNING ANALYSIS REPORT

Facility

$181.00

Service Code	HCPCS 93226
Hospital Charge Code	4150525
Hospital Revenue Code	731
Min. Negotiated Rate	$117.65
Max. Negotiated Rate	$117.65
Rate for Payer: Cash Price	$135.75
Rate for Payer: Galaxy Health Commercial	$117.65

EXTERNAL ECG SCANNING ANALYSIS REPORT

Facility

$181.00

Service Code	HCPCS 93226
Hospital Charge Code	4150525
Hospital Revenue Code	731
Min. Negotiated Rate	$27.15
Max. Negotiated Rate	$144.80
Rate for Payer: Aetna of NY Commercial	$117.65
Rate for Payer: Aetna of NY Medicare	$83.26
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$72.40
Rate for Payer: Cash Price	$135.75
Rate for Payer: CDPHP Medicare	$66.97
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$126.70
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$144.80
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$144.80
Rate for Payer: EmblemHealth Medicaid	$144.80
Rate for Payer: EmblemHealth Medicare	$61.54
Rate for Payer: EmblemHealth Select Care	$117.65
Rate for Payer: Fidelis Medicare	$72.40
Rate for Payer: Galaxy Health Commercial	$117.65
Rate for Payer: Hamaspik Choice Medicare	$72.40
Rate for Payer: Humana Medicare	$72.40
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$117.65
Rate for Payer: Local 1199SEIU Medicare	$83.26
Rate for Payer: MVP Health Care of NY Commercial	$135.75
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$101.90
Rate for Payer: MVP Health Care of NY Medicare	$76.02
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$27.15
Rate for Payer: United Healthcare Medicare	$72.40
Rate for Payer: WellCare Medicare	$99.55

EXTREMITY DRAPE

Facility

$39.14

Hospital Charge Code	4479127
Hospital Revenue Code	270
Min. Negotiated Rate	$5.87
Max. Negotiated Rate	$31.31
Rate for Payer: Aetna of NY Commercial	$27.40
Rate for Payer: Aetna of NY Medicare	$18.00
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$15.66
Rate for Payer: Cash Price	$29.36
Rate for Payer: CDPHP Medicare	$14.48
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$31.31
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$31.31
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$31.31
Rate for Payer: EmblemHealth Medicaid	$31.31
Rate for Payer: EmblemHealth Medicare	$13.31
Rate for Payer: EmblemHealth Select Care	$28.18
Rate for Payer: Fidelis Medicare	$15.66
Rate for Payer: Galaxy Health Commercial	$25.44
Rate for Payer: Hamaspik Choice Medicare	$15.66
Rate for Payer: Humana Medicare	$15.66
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$27.40
Rate for Payer: Local 1199SEIU Medicare	$18.00
Rate for Payer: MVP Health Care of NY Commercial	$29.36
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$22.04
Rate for Payer: MVP Health Care of NY Medicare	$16.44
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$5.87
Rate for Payer: United Healthcare Medicare	$15.66
Rate for Payer: WellCare Medicare	$21.53

EXTREMITY DRAPE

Facility

$39.14

Hospital Charge Code	4479127
Hospital Revenue Code	270
Min. Negotiated Rate	$25.44
Max. Negotiated Rate	$25.44
Rate for Payer: Cash Price	$29.36
Rate for Payer: Galaxy Health Commercial	$25.44

EYE DROPS (GENERIC VISINE)

Facility

$6.44

Service Code	NDC 74300000803
Hospital Charge Code	4409002
Hospital Revenue Code	250
Min. Negotiated Rate	$3.54
Max. Negotiated Rate	$4.19
Rate for Payer: Cash Price	$4.83
Rate for Payer: Galaxy Health Commercial	$4.19
Rate for Payer: WellCare Medicare	$3.54

EYE DROPS (GENERIC VISINE)

Facility

$6.44

Service Code	NDC 74300000803
Hospital Charge Code	4409002
Hospital Revenue Code	250
Min. Negotiated Rate	$0.97
Max. Negotiated Rate	$5.15
Rate for Payer: Aetna of NY Commercial	$4.51
Rate for Payer: Aetna of NY Medicare	$2.96
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$2.58
Rate for Payer: Cash Price	$4.83
Rate for Payer: CDPHP Medicare	$2.38
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$5.15
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$5.15
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$5.15
Rate for Payer: EmblemHealth Medicaid	$5.15
Rate for Payer: EmblemHealth Medicare	$2.19
Rate for Payer: EmblemHealth Select Care	$4.64
Rate for Payer: Fidelis Medicare	$2.58
Rate for Payer: Galaxy Health Commercial	$4.19
Rate for Payer: Hamaspik Choice Medicare	$2.58
Rate for Payer: Humana Medicare	$2.58
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$4.51
Rate for Payer: Local 1199SEIU Medicare	$2.96
Rate for Payer: MVP Health Care of NY Commercial	$4.83
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$3.63
Rate for Payer: MVP Health Care of NY Medicare	$2.70
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$0.97
Rate for Payer: United Healthcare Medicare	$2.58
Rate for Payer: WellCare Medicare	$3.54

EYE TRAY

Facility

$53.56

Hospital Charge Code	4479120
Hospital Revenue Code	270
Min. Negotiated Rate	$34.81
Max. Negotiated Rate	$34.81
Rate for Payer: Cash Price	$40.17
Rate for Payer: Galaxy Health Commercial	$34.81

EYE TRAY

Facility

$53.56

Hospital Charge Code	4479120
Hospital Revenue Code	270
Min. Negotiated Rate	$8.03
Max. Negotiated Rate	$42.85
Rate for Payer: Aetna of NY Commercial	$37.49
Rate for Payer: Aetna of NY Medicare	$24.64
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$21.42
Rate for Payer: Cash Price	$40.17
Rate for Payer: CDPHP Medicare	$19.82
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$42.85
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$42.85
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$42.85
Rate for Payer: EmblemHealth Medicaid	$42.85
Rate for Payer: EmblemHealth Medicare	$18.21
Rate for Payer: EmblemHealth Select Care	$38.56
Rate for Payer: Fidelis Medicare	$21.42
Rate for Payer: Galaxy Health Commercial	$34.81
Rate for Payer: Hamaspik Choice Medicare	$21.42
Rate for Payer: Humana Medicare	$21.42
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$37.49
Rate for Payer: Local 1199SEIU Medicare	$24.64
Rate for Payer: MVP Health Care of NY Commercial	$40.17
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$30.15
Rate for Payer: MVP Health Care of NY Medicare	$22.50
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$8.03
Rate for Payer: United Healthcare Medicare	$21.42
Rate for Payer: WellCare Medicare	$29.46

EZETIMIBE 10 MG TABLET 10 mg, 1 each

Facility

$37.50

Service Code	NDC 904666404
Hospital Charge Code	4401319
Hospital Revenue Code	250
Min. Negotiated Rate	$20.62
Max. Negotiated Rate	$24.38
Rate for Payer: Cash Price	$28.12
Rate for Payer: Galaxy Health Commercial	$24.38
Rate for Payer: WellCare Medicare	$20.62

EZETIMIBE 10 MG TABLET 10 mg, 1 each

Facility

$37.50

Service Code	NDC 904666404
Hospital Charge Code	4401319
Hospital Revenue Code	250
Min. Negotiated Rate	$5.62
Max. Negotiated Rate	$30.00
Rate for Payer: Aetna of NY Commercial	$26.25
Rate for Payer: Aetna of NY Medicare	$17.25
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$15.00
Rate for Payer: Cash Price	$28.12
Rate for Payer: CDPHP Medicare	$13.88
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$30.00
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$30.00
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$30.00
Rate for Payer: EmblemHealth Medicaid	$30.00
Rate for Payer: EmblemHealth Medicare	$12.75
Rate for Payer: EmblemHealth Select Care	$27.00
Rate for Payer: Fidelis Medicare	$15.00
Rate for Payer: Galaxy Health Commercial	$24.38
Rate for Payer: Hamaspik Choice Medicare	$15.00
Rate for Payer: Humana Medicare	$15.00
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$26.25
Rate for Payer: Local 1199SEIU Medicare	$17.25
Rate for Payer: MVP Health Care of NY Commercial	$28.12
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$21.11
Rate for Payer: MVP Health Care of NY Medicare	$15.75
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$5.62
Rate for Payer: United Healthcare Medicare	$15.00
Rate for Payer: WellCare Medicare	$20.62

EZETIMIBE 10MG TABS 10X10EA

Facility

$35.28

Service Code	NDC 66582041429
Hospital Charge Code	4400820
Hospital Revenue Code	250
Min. Negotiated Rate	$5.29
Max. Negotiated Rate	$28.22
Rate for Payer: Aetna of NY Commercial	$24.70
Rate for Payer: Aetna of NY Medicare	$16.23
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$14.11
Rate for Payer: Cash Price	$26.46
Rate for Payer: CDPHP Medicare	$13.05
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$28.22
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$28.22
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$28.22
Rate for Payer: EmblemHealth Medicaid	$28.22
Rate for Payer: EmblemHealth Medicare	$12.00
Rate for Payer: EmblemHealth Select Care	$25.40
Rate for Payer: Fidelis Medicare	$14.11
Rate for Payer: Galaxy Health Commercial	$22.93
Rate for Payer: Hamaspik Choice Medicare	$14.11
Rate for Payer: Humana Medicare	$14.11
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$24.70
Rate for Payer: Local 1199SEIU Medicare	$16.23
Rate for Payer: MVP Health Care of NY Commercial	$26.46
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$19.86
Rate for Payer: MVP Health Care of NY Medicare	$14.82
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$5.29
Rate for Payer: United Healthcare Medicare	$14.11
Rate for Payer: WellCare Medicare	$19.40

EZETIMIBE 10MG TABS 10X10EA

Facility

$35.28

Service Code	NDC 66582041429
Hospital Charge Code	4400820
Hospital Revenue Code	250
Min. Negotiated Rate	$19.40
Max. Negotiated Rate	$22.93
Rate for Payer: Cash Price	$26.46
Rate for Payer: Galaxy Health Commercial	$22.93
Rate for Payer: WellCare Medicare	$19.40

EZ-IO AD 15G INTRAOSSEOUS NEE

Facility

$450.11

Hospital Charge Code	4471982
Hospital Revenue Code	270
Min. Negotiated Rate	$67.52
Max. Negotiated Rate	$360.09
Rate for Payer: Aetna of NY Commercial	$315.08
Rate for Payer: Aetna of NY Medicare	$207.05
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$180.04
Rate for Payer: Cash Price	$337.58
Rate for Payer: CDPHP Medicare	$166.54
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$360.09
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$360.09
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$360.09
Rate for Payer: EmblemHealth Medicaid	$360.09
Rate for Payer: EmblemHealth Medicare	$153.04
Rate for Payer: EmblemHealth Select Care	$324.08
Rate for Payer: Fidelis Medicare	$180.04
Rate for Payer: Galaxy Health Commercial	$292.57
Rate for Payer: Hamaspik Choice Medicare	$180.04
Rate for Payer: Humana Medicare	$180.04
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$315.08
Rate for Payer: Local 1199SEIU Medicare	$207.05
Rate for Payer: MVP Health Care of NY Commercial	$337.58
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$253.41
Rate for Payer: MVP Health Care of NY Medicare	$189.05
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$67.52
Rate for Payer: United Healthcare Medicare	$180.04
Rate for Payer: WellCare Medicare	$247.56

EZ-IO AD 15G INTRAOSSEOUS NEE

Facility

$450.11

Hospital Charge Code	4471981
Hospital Revenue Code	270
Min. Negotiated Rate	$67.52
Max. Negotiated Rate	$360.09
Rate for Payer: Aetna of NY Commercial	$315.08
Rate for Payer: Aetna of NY Medicare	$207.05
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$180.04
Rate for Payer: Cash Price	$337.58
Rate for Payer: CDPHP Medicare	$166.54
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$360.09
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$360.09
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$360.09
Rate for Payer: EmblemHealth Medicaid	$360.09
Rate for Payer: EmblemHealth Medicare	$153.04
Rate for Payer: EmblemHealth Select Care	$324.08
Rate for Payer: Fidelis Medicare	$180.04
Rate for Payer: Galaxy Health Commercial	$292.57
Rate for Payer: Hamaspik Choice Medicare	$180.04
Rate for Payer: Humana Medicare	$180.04
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$315.08
Rate for Payer: Local 1199SEIU Medicare	$207.05
Rate for Payer: MVP Health Care of NY Commercial	$337.58
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$253.41
Rate for Payer: MVP Health Care of NY Medicare	$189.05
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$67.52
Rate for Payer: United Healthcare Medicare	$180.04
Rate for Payer: WellCare Medicare	$247.56

EZ-IO AD 15G INTRAOSSEOUS NEE

Facility

$450.11

Hospital Charge Code	4471982
Hospital Revenue Code	270
Min. Negotiated Rate	$292.57
Max. Negotiated Rate	$292.57
Rate for Payer: Cash Price	$337.58
Rate for Payer: Galaxy Health Commercial	$292.57

EZ-IO AD 15G INTRAOSSEOUS NEE

Facility

$450.11

Hospital Charge Code	4471981
Hospital Revenue Code	270
Min. Negotiated Rate	$292.57
Max. Negotiated Rate	$292.57
Rate for Payer: Cash Price	$337.58
Rate for Payer: Galaxy Health Commercial	$292.57

EZ-IO LD 15G 45MM IO NEE

Facility

$450.11

Hospital Charge Code	4471983
Hospital Revenue Code	270
Min. Negotiated Rate	$67.52
Max. Negotiated Rate	$360.09
Rate for Payer: Aetna of NY Commercial	$315.08
Rate for Payer: Aetna of NY Medicare	$207.05
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$180.04
Rate for Payer: Cash Price	$337.58
Rate for Payer: CDPHP Medicare	$166.54
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$360.09
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$360.09
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$360.09
Rate for Payer: EmblemHealth Medicaid	$360.09
Rate for Payer: EmblemHealth Medicare	$153.04
Rate for Payer: EmblemHealth Select Care	$324.08
Rate for Payer: Fidelis Medicare	$180.04
Rate for Payer: Galaxy Health Commercial	$292.57
Rate for Payer: Hamaspik Choice Medicare	$180.04
Rate for Payer: Humana Medicare	$180.04
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$315.08
Rate for Payer: Local 1199SEIU Medicare	$207.05
Rate for Payer: MVP Health Care of NY Commercial	$337.58
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$253.41
Rate for Payer: MVP Health Care of NY Medicare	$189.05
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$67.52
Rate for Payer: United Healthcare Medicare	$180.04
Rate for Payer: WellCare Medicare	$247.56

EZ-IO LD 15G 45MM IO NEE

Facility

$450.11

Hospital Charge Code	4471983
Hospital Revenue Code	270
Min. Negotiated Rate	$292.57
Max. Negotiated Rate	$292.57
Rate for Payer: Cash Price	$337.58
Rate for Payer: Galaxy Health Commercial	$292.57

Know your out-of-pocket cost for care.

All Charges