Ellenville Regional Hospital

All Charges

Charge

Type

Setting

Price

FRESH FROZEN PLASMA

Facility

$452.00

Service Code	HCPCS P9021
Hospital Charge Code	4304876
Hospital Revenue Code	390
Min. Negotiated Rate	$67.80
Max. Negotiated Rate	$361.60
Rate for Payer: Aetna of NY Commercial	$316.40
Rate for Payer: Aetna of NY Medicare	$207.92
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$180.80
Rate for Payer: Cash Price	$339.00
Rate for Payer: CDPHP Medicare	$167.24
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$226.00
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$361.60
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$361.60
Rate for Payer: EmblemHealth Medicaid	$361.60
Rate for Payer: EmblemHealth Medicare	$153.68
Rate for Payer: EmblemHealth Select Care	$226.00
Rate for Payer: Fidelis Medicare	$180.80
Rate for Payer: Galaxy Health Commercial	$293.80
Rate for Payer: Hamaspik Choice Medicare	$180.80
Rate for Payer: Humana Medicare	$180.80
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$316.40
Rate for Payer: Local 1199SEIU Medicare	$207.92
Rate for Payer: MVP Health Care of NY Commercial	$339.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$254.48
Rate for Payer: MVP Health Care of NY Medicare	$189.84
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$339.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$67.80
Rate for Payer: United Healthcare Commercial	$339.00
Rate for Payer: United Healthcare Medicare	$180.80
Rate for Payer: WellCare Medicare	$248.60

FUROSEMIDE 20MG TABS 10X10EA

Facility

$6.18

Service Code	NDC 51079007201
Hospital Charge Code	4400312
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

FUROSEMIDE 20MG TABS 10X10EA

Facility

$6.18

Service Code	NDC 51079007201
Hospital Charge Code	4400312
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

FUROSEMIDE 40 MG/4 ML VIAL 10 mg, 4 mL

Facility

$6.00

Service Code	HCPCS J1940
Hospital Charge Code	4401517
Hospital Revenue Code	636
Min. Negotiated Rate	$3.30
Max. Negotiated Rate	$3.90
Rate for Payer: Aetna of NY Commercial	$3.30
Rate for Payer: Cash Price	$4.50
Rate for Payer: Galaxy Health Commercial	$3.90
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$3.30
Rate for Payer: WellCare Medicare	$3.30

FUROSEMIDE 40 MG/4 ML VIAL 10 mg, 4 mL

Facility

$6.00

Service Code	HCPCS J1940
Hospital Charge Code	4401517
Hospital Revenue Code	636
Min. Negotiated Rate	$0.83
Max. Negotiated Rate	$4.80
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: 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 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: Oxford Health Plans Freedom/Liberty/Metro	$0.83
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$0.90
Rate for Payer: United Healthcare Commercial	$0.83
Rate for Payer: United Healthcare Medicare	$2.40
Rate for Payer: WellCare Medicare	$3.30

FUROSEMIDE 40MG TABS 100 EA

Facility

$6.18

Service Code	NDC 54829925
Hospital Charge Code	4400313
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

FUROSEMIDE 40MG TABS 100 EA

Facility

$6.18

Service Code	NDC 54829925
Hospital Charge Code	4400313
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

FUROSEMIDE INJ, UP TO 20 MG

Facility

$18.80

Service Code	HCPCS J1940
Hospital Charge Code	4400311
Hospital Revenue Code	636
Min. Negotiated Rate	$10.34
Max. Negotiated Rate	$12.22
Rate for Payer: Aetna of NY Commercial	$10.34
Rate for Payer: Cash Price	$14.10
Rate for Payer: Galaxy Health Commercial	$12.22
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$10.34
Rate for Payer: WellCare Medicare	$10.34

FUROSEMIDE INJ, UP TO 20 MG

Facility

$18.80

Service Code	HCPCS J1940
Hospital Charge Code	4400311
Hospital Revenue Code	636
Min. Negotiated Rate	$0.83
Max. Negotiated Rate	$15.04
Rate for Payer: Aetna of NY Medicare	$8.65
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$7.52
Rate for Payer: Cash Price	$14.10
Rate for Payer: Cash Price	$14.10
Rate for Payer: CDPHP Medicare	$6.96
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$15.04
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$15.04
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$15.04
Rate for Payer: EmblemHealth Medicaid	$15.04
Rate for Payer: EmblemHealth Medicare	$6.39
Rate for Payer: EmblemHealth Select Care	$13.54
Rate for Payer: Fidelis Medicare	$7.52
Rate for Payer: Galaxy Health Commercial	$12.22
Rate for Payer: Hamaspik Choice Medicare	$7.52
Rate for Payer: Humana Medicare	$7.52
Rate for Payer: Local 1199SEIU Medicare	$8.65
Rate for Payer: MVP Health Care of NY Commercial	$14.10
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$10.58
Rate for Payer: MVP Health Care of NY Medicare	$7.90
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$0.83
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$2.82
Rate for Payer: United Healthcare Commercial	$0.83
Rate for Payer: United Healthcare Medicare	$7.52
Rate for Payer: WellCare Medicare	$10.34

GABAPENTIN 100MG CAPS 10X10EA

Facility

$6.18

Service Code	NDC 63739059110
Hospital Charge Code	4400315
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

GABAPENTIN 100MG CAPS 10X10EA

Facility

$6.18

Service Code	NDC 63739059110
Hospital Charge Code	4400315
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

GABAPENTIN 300MG CAPS 10X10EA

Facility

$6.18

Service Code	NDC 68084076211
Hospital Charge Code	4400317
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

GABAPENTIN 300MG CAPS 10X10EA

Facility

$6.18

Service Code	NDC 68084076211
Hospital Charge Code	4400317
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

GABAPENTIN 400MG CAPS 10X10EA

Facility

$7.25

Service Code	NDC 68084077411
Hospital Charge Code	4400316
Hospital Revenue Code	250
Min. Negotiated Rate	$1.09
Max. Negotiated Rate	$5.80
Rate for Payer: Aetna of NY Commercial	$5.08
Rate for Payer: Aetna of NY Medicare	$3.33
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$2.90
Rate for Payer: Cash Price	$5.44
Rate for Payer: CDPHP Medicare	$2.68
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$5.80
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$5.80
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$5.80
Rate for Payer: EmblemHealth Medicaid	$5.80
Rate for Payer: EmblemHealth Medicare	$2.46
Rate for Payer: EmblemHealth Select Care	$5.22
Rate for Payer: Fidelis Medicare	$2.90
Rate for Payer: Galaxy Health Commercial	$4.71
Rate for Payer: Hamaspik Choice Medicare	$2.90
Rate for Payer: Humana Medicare	$2.90
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$5.08
Rate for Payer: Local 1199SEIU Medicare	$3.33
Rate for Payer: MVP Health Care of NY Commercial	$5.44
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$4.08
Rate for Payer: MVP Health Care of NY Medicare	$3.04
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$1.09
Rate for Payer: United Healthcare Medicare	$2.90
Rate for Payer: WellCare Medicare	$3.99

GABAPENTIN 400MG CAPS 10X10EA

Facility

$7.25

Service Code	NDC 68084077411
Hospital Charge Code	4400316
Hospital Revenue Code	250
Min. Negotiated Rate	$3.99
Max. Negotiated Rate	$4.71
Rate for Payer: Cash Price	$5.44
Rate for Payer: Galaxy Health Commercial	$4.71
Rate for Payer: WellCare Medicare	$3.99

GAD-BASE MR CONTRAST NOS PER 1 ML (OPTIMARK)

Facility

$299.73

Service Code	HCPCS A9579
Hospital Charge Code	4231000
Hospital Revenue Code	636
Min. Negotiated Rate	$1.45
Max. Negotiated Rate	$239.78
Rate for Payer: Aetna of NY Medicare	$137.88
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$119.89
Rate for Payer: Cash Price	$224.80
Rate for Payer: Cash Price	$224.80
Rate for Payer: CDPHP Medicare	$110.90
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$1.45
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$239.78
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$239.78
Rate for Payer: EmblemHealth Medicaid	$239.78
Rate for Payer: EmblemHealth Medicare	$101.91
Rate for Payer: EmblemHealth Select Care	$1.45
Rate for Payer: Fidelis Medicare	$119.89
Rate for Payer: Galaxy Health Commercial	$194.82
Rate for Payer: Hamaspik Choice Medicare	$119.89
Rate for Payer: Humana Medicare	$119.89
Rate for Payer: Local 1199SEIU Medicare	$137.88
Rate for Payer: MVP Health Care of NY Commercial	$224.80
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$168.75
Rate for Payer: MVP Health Care of NY Medicare	$125.89
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$2.56
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$44.96
Rate for Payer: United Healthcare Commercial	$2.56
Rate for Payer: United Healthcare Medicare	$119.89
Rate for Payer: WellCare Medicare	$164.85

GAD-BASE MR CONTRAST NOS PER 1 ML (OPTIMARK)

Facility

$299.73

Service Code	HCPCS A9579
Hospital Charge Code	4231000
Hospital Revenue Code	636
Min. Negotiated Rate	$1.45
Max. Negotiated Rate	$194.82
Rate for Payer: Aetna of NY Commercial	$164.85
Rate for Payer: Cash Price	$224.80
Rate for Payer: Cash Price	$224.80
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$1.45
Rate for Payer: EmblemHealth Select Care	$1.45
Rate for Payer: Galaxy Health Commercial	$194.82
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$164.85
Rate for Payer: WellCare Medicare	$164.85

GALLIUM 67 (PER MCI)

Facility

$69.01

Service Code	HCPCS A9556
Hospital Charge Code	4211243
Hospital Revenue Code	343
Min. Negotiated Rate	$44.86
Max. Negotiated Rate	$44.86
Rate for Payer: Cash Price	$51.76
Rate for Payer: Galaxy Health Commercial	$44.86

GALLIUM 67 (PER MCI)

Facility

$69.01

Service Code	HCPCS A9556
Hospital Charge Code	4211243
Hospital Revenue Code	343
Min. Negotiated Rate	$10.35
Max. Negotiated Rate	$55.21
Rate for Payer: Aetna of NY Medicare	$31.74
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$27.60
Rate for Payer: Cash Price	$51.76
Rate for Payer: Cash Price	$51.76
Rate for Payer: CDPHP Medicare	$25.53
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$55.21
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$55.21
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$55.21
Rate for Payer: EmblemHealth Medicaid	$55.21
Rate for Payer: EmblemHealth Medicare	$23.46
Rate for Payer: EmblemHealth Select Care	$49.69
Rate for Payer: Fidelis Medicare	$27.60
Rate for Payer: Galaxy Health Commercial	$44.86
Rate for Payer: Hamaspik Choice Medicare	$27.60
Rate for Payer: Humana Medicare	$27.60
Rate for Payer: Local 1199SEIU Medicare	$31.74
Rate for Payer: MVP Health Care of NY Commercial	$51.76
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$38.85
Rate for Payer: MVP Health Care of NY Medicare	$28.98
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$38.02
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$10.35
Rate for Payer: United Healthcare Commercial	$38.02
Rate for Payer: United Healthcare Medicare	$27.60
Rate for Payer: WellCare Medicare	$37.96

GAMMA GLUT TRANS (GGT)

Facility

$22.00

Service Code	HCPCS 82977
Hospital Charge Code	4300365
Hospital Revenue Code	301
Min. Negotiated Rate	$14.30
Max. Negotiated Rate	$14.30
Rate for Payer: Cash Price	$16.50
Rate for Payer: Galaxy Health Commercial	$14.30

GAMMA GLUT TRANS (GGT)

Facility

$22.00

Service Code	HCPCS 82977
Hospital Charge Code	4300365
Hospital Revenue Code	301
Min. Negotiated Rate	$3.30
Max. Negotiated Rate	$17.60
Rate for Payer: Aetna of NY Commercial	$14.30
Rate for Payer: Aetna of NY Medicare	$10.12
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$8.80
Rate for Payer: Cash Price	$16.50
Rate for Payer: CDPHP Medicare	$8.14
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$13.20
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$17.60
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$17.60
Rate for Payer: EmblemHealth Medicaid	$17.60
Rate for Payer: EmblemHealth Medicare	$7.48
Rate for Payer: EmblemHealth Select Care	$13.20
Rate for Payer: Fidelis Medicare	$8.80
Rate for Payer: Galaxy Health Commercial	$14.30
Rate for Payer: Hamaspik Choice Medicare	$8.80
Rate for Payer: Humana Medicare	$8.80
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$14.30
Rate for Payer: Local 1199SEIU Medicare	$10.12
Rate for Payer: MVP Health Care of NY Commercial	$16.50
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$12.39
Rate for Payer: MVP Health Care of NY Medicare	$9.24
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$16.50
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$3.30
Rate for Payer: United Healthcare Commercial	$16.50
Rate for Payer: United Healthcare Medicare	$8.80
Rate for Payer: WellCare Medicare	$12.10

GANGLION CYST INJ OR ASPIR

Facility

$941.00

Service Code	HCPCS 20612
Hospital Charge Code	4850032
Hospital Revenue Code	761
Min. Negotiated Rate	$611.65
Max. Negotiated Rate	$611.65
Rate for Payer: Cash Price	$705.75
Rate for Payer: Galaxy Health Commercial	$611.65

GANGLION CYST INJ OR ASPIR

Facility

$941.00

Service Code	HCPCS 20612
Hospital Charge Code	4850032
Hospital Revenue Code	761
Min. Negotiated Rate	$141.15
Max. Negotiated Rate	$752.80
Rate for Payer: Aetna of NY Commercial	$658.70
Rate for Payer: Aetna of NY Medicare	$432.86
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$376.40
Rate for Payer: Cash Price	$705.75
Rate for Payer: CDPHP Medicare	$348.17
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$752.80
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$752.80
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$752.80
Rate for Payer: EmblemHealth Medicaid	$752.80
Rate for Payer: EmblemHealth Medicare	$319.94
Rate for Payer: EmblemHealth Select Care	$677.52
Rate for Payer: Fidelis Medicare	$376.40
Rate for Payer: Galaxy Health Commercial	$611.65
Rate for Payer: Hamaspik Choice Medicare	$376.40
Rate for Payer: Humana Medicare	$376.40
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$658.70
Rate for Payer: Local 1199SEIU Medicare	$432.86
Rate for Payer: MVP Health Care of NY Commercial	$705.75
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$529.78
Rate for Payer: MVP Health Care of NY Medicare	$395.22
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$141.15
Rate for Payer: United Healthcare Medicare	$376.40
Rate for Payer: WellCare Medicare	$517.55

GARAMYCIN GENTAMICIN INJ, UP TO 80 MG

Facility

$11.85

Service Code	HCPCS J1580
Hospital Charge Code	4400322
Hospital Revenue Code	636
Min. Negotiated Rate	$1.78
Max. Negotiated Rate	$9.48
Rate for Payer: Aetna of NY Medicare	$5.45
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$4.74
Rate for Payer: Cash Price	$8.89
Rate for Payer: Cash Price	$8.89
Rate for Payer: CDPHP Medicare	$4.38
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$1.93
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$9.48
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$9.48
Rate for Payer: EmblemHealth Medicaid	$9.48
Rate for Payer: EmblemHealth Medicare	$4.03
Rate for Payer: EmblemHealth Select Care	$1.93
Rate for Payer: Fidelis Medicare	$4.74
Rate for Payer: Galaxy Health Commercial	$7.70
Rate for Payer: Hamaspik Choice Medicare	$4.74
Rate for Payer: Humana Medicare	$4.74
Rate for Payer: Local 1199SEIU Medicare	$5.45
Rate for Payer: MVP Health Care of NY Commercial	$8.89
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$6.67
Rate for Payer: MVP Health Care of NY Medicare	$4.98
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$4.93
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$1.78
Rate for Payer: United Healthcare Commercial	$4.93
Rate for Payer: United Healthcare Medicare	$4.74
Rate for Payer: WellCare Medicare	$6.52

GARAMYCIN GENTAMICIN INJ, UP TO 80 MG

Facility

$11.85

Service Code	HCPCS J1580
Hospital Charge Code	4400322
Hospital Revenue Code	636
Min. Negotiated Rate	$1.93
Max. Negotiated Rate	$7.70
Rate for Payer: Aetna of NY Commercial	$6.52
Rate for Payer: Cash Price	$8.89
Rate for Payer: Cash Price	$8.89
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$1.93
Rate for Payer: EmblemHealth Select Care	$1.93
Rate for Payer: Galaxy Health Commercial	$7.70
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$6.52
Rate for Payer: WellCare Medicare	$6.52

Know your out-of-pocket cost for care.

All Charges