Ellenville Regional Hospital

All Charges

Charge

Type

Setting

Price

IMMUNOASSAY QUANT NOS NONAB

Facility

$52.00

Service Code	HCPCS 83520
Hospital Charge Code	4301073
Hospital Revenue Code	300
Min. Negotiated Rate	$7.80
Max. Negotiated Rate	$41.60
Rate for Payer: Aetna of NY Commercial	$33.80
Rate for Payer: Aetna of NY Medicare	$23.92
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$20.80
Rate for Payer: Cash Price	$39.00
Rate for Payer: CDPHP Medicare	$19.24
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$31.20
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$41.60
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$41.60
Rate for Payer: EmblemHealth Medicaid	$41.60
Rate for Payer: EmblemHealth Medicare	$17.68
Rate for Payer: EmblemHealth Select Care	$31.20
Rate for Payer: Fidelis Medicare	$20.80
Rate for Payer: Galaxy Health Commercial	$33.80
Rate for Payer: Hamaspik Choice Medicare	$20.80
Rate for Payer: Humana Medicare	$20.80
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$33.80
Rate for Payer: Local 1199SEIU Medicare	$23.92
Rate for Payer: MVP Health Care of NY Commercial	$39.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$29.28
Rate for Payer: MVP Health Care of NY Medicare	$21.84
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$39.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$7.80
Rate for Payer: United Healthcare Commercial	$39.00
Rate for Payer: United Healthcare Medicare	$20.80
Rate for Payer: WellCare Medicare	$28.60

IMMUNOASSAY QUANT NOS NONAB

Facility

$52.00

Service Code	HCPCS 83520
Hospital Charge Code	4301073
Hospital Revenue Code	300
Min. Negotiated Rate	$33.80
Max. Negotiated Rate	$33.80
Rate for Payer: Cash Price	$39.00
Rate for Payer: Galaxy Health Commercial	$33.80

IM OR SUBCUTANEOUS

Facility

$221.00

Service Code	HCPCS 96372
Hospital Charge Code	4450101
Hospital Revenue Code	260
Min. Negotiated Rate	$13.09
Max. Negotiated Rate	$176.80
Rate for Payer: Aetna of NY Commercial	$154.70
Rate for Payer: Aetna of NY Medicare	$101.66
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$88.40
Rate for Payer: Cash Price	$165.75
Rate for Payer: Cash Price	$165.75
Rate for Payer: CDPHP Medicare	$81.77
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$176.80
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$16.03
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$13.36
Rate for Payer: EmblemHealth Medicaid	$13.36
Rate for Payer: EmblemHealth Medicare	$75.14
Rate for Payer: EmblemHealth Select Care	$159.12
Rate for Payer: Fidelis Medicare	$88.40
Rate for Payer: Galaxy Health Commercial	$143.65
Rate for Payer: Galaxy Health Workers Comp	$13.09
Rate for Payer: Hamaspik Choice Medicaid	$13.36
Rate for Payer: Hamaspik Choice Medicare	$88.40
Rate for Payer: Humana Medicare	$88.40
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$154.70
Rate for Payer: Local 1199SEIU Medicare	$101.66
Rate for Payer: MVP Health Care of NY Child Health Plus/Family Health Plus/HARP/Medicaid	$14.03
Rate for Payer: MVP Health Care of NY Commercial	$165.75
Rate for Payer: MVP Health Care of NY Essential Plan 1&2	$28.72
Rate for Payer: MVP Health Care of NY Essential Plan 3&4	$28.72
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$124.42
Rate for Payer: MVP Health Care of NY Medicare	$92.82
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$165.75
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$33.15
Rate for Payer: United Healthcare Commercial	$165.75
Rate for Payer: United Healthcare Medicare	$88.40
Rate for Payer: WellCare Child Health Plus/Family Health Plus/Medicaid	$14.03
Rate for Payer: WellCare Medicare	$121.55

IM OR SUBCUTANEOUS

Facility

$221.00

Service Code	HCPCS 96372
Hospital Charge Code	4450101
Hospital Revenue Code	260
Min. Negotiated Rate	$143.65
Max. Negotiated Rate	$143.65
Rate for Payer: Cash Price	$165.75
Rate for Payer: Galaxy Health Commercial	$143.65

IMPLANTABLE BIOPSY SITE MARKER

Facility

$286.34

Service Code	HCPCS A4648
Hospital Charge Code	4473021
Hospital Revenue Code	278
Min. Negotiated Rate	$42.95
Max. Negotiated Rate	$229.07
Rate for Payer: Aetna of NY Commercial	$200.44
Rate for Payer: Aetna of NY Medicare	$131.72
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$114.54
Rate for Payer: Cash Price	$214.76
Rate for Payer: CDPHP Medicare	$105.95
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$143.17
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$229.07
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$229.07
Rate for Payer: EmblemHealth Medicaid	$229.07
Rate for Payer: EmblemHealth Medicare	$97.36
Rate for Payer: EmblemHealth Select Care	$143.17
Rate for Payer: Fidelis Medicare	$114.54
Rate for Payer: Galaxy Health Commercial	$186.12
Rate for Payer: Hamaspik Choice Medicare	$114.54
Rate for Payer: Humana Medicare	$114.54
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$200.44
Rate for Payer: Local 1199SEIU Medicare	$131.72
Rate for Payer: MVP Health Care of NY Commercial	$186.12
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$186.12
Rate for Payer: MVP Health Care of NY Medicare	$120.26
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$42.95
Rate for Payer: United Healthcare Medicare	$114.54
Rate for Payer: WellCare Medicare	$157.49

IMPLANTABLE BIOPSY SITE MARKER

Facility

$286.34

Service Code	HCPCS A4648
Hospital Charge Code	4473021
Hospital Revenue Code	278
Min. Negotiated Rate	$128.85
Max. Negotiated Rate	$200.44
Rate for Payer: Aetna of NY Commercial	$200.44
Rate for Payer: Cash Price	$214.76
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$143.17
Rate for Payer: EmblemHealth Select Care	$143.17
Rate for Payer: Galaxy Health Commercial	$186.12
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$200.44
Rate for Payer: Multiplan Commercial	$128.85
Rate for Payer: MVP Health Care of NY Commercial	$186.12
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$186.12
Rate for Payer: WellCare Medicare	$157.49

IMPLANTATION OR REPLACEMENT OF DEVICE FOR INTRATHECAL OR EPIDURAL DRUG INFUSION; PROGRAMMABLE PUMP, INCLUDING PREPARATION OF PUMP, WITH OR WITHOUT PROGRAMMING

Facility

$16,992.38

Service Code	CPT 62362
Hospital Revenue Code	490
Min. Negotiated Rate	$1,900.00
Max. Negotiated Rate	$16,992.38
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	$2,763.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$16,992.38
Rate for Payer: United Healthcare Commercial	$2,763.00

IMPLANTATION, REVISION OR REPOSITIONING OF TUNNELED INTRATHECAL OR EPIDURAL CATHETER, FOR LONG-TERM MEDICATION ADMINISTRATION VIA AN EXTERNAL PUMP OR IMPLANTABLE RESERVOIR/INFUSION PUMP; WITHOUT LAMINECTOMY

Facility

$6,346.97

Service Code	CPT 62350
Hospital Revenue Code	490
Min. Negotiated Rate	$1,900.00
Max. Negotiated Rate	$6,346.97
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	$2,097.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$6,346.97
Rate for Payer: United Healthcare Commercial	$2,097.00

INCAL BX SKN EA SEP/ADDL

Facility

$232.00

Service Code	HCPCS 11107
Hospital Charge Code	4853030
Hospital Revenue Code	761
Min. Negotiated Rate	$34.80
Max. Negotiated Rate	$185.60
Rate for Payer: Aetna of NY Commercial	$162.40
Rate for Payer: Aetna of NY Medicare	$106.72
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$92.80
Rate for Payer: Cash Price	$174.00
Rate for Payer: CDPHP Medicare	$85.84
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$185.60
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$185.60
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$185.60
Rate for Payer: EmblemHealth Medicaid	$185.60
Rate for Payer: EmblemHealth Medicare	$78.88
Rate for Payer: EmblemHealth Select Care	$167.04
Rate for Payer: Fidelis Medicare	$92.80
Rate for Payer: Galaxy Health Commercial	$150.80
Rate for Payer: Hamaspik Choice Medicare	$92.80
Rate for Payer: Humana Medicare	$92.80
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$162.40
Rate for Payer: Local 1199SEIU Medicare	$106.72
Rate for Payer: MVP Health Care of NY Commercial	$174.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$130.62
Rate for Payer: MVP Health Care of NY Medicare	$97.44
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$34.80
Rate for Payer: United Healthcare Medicare	$92.80
Rate for Payer: WellCare Medicare	$127.60

INCAL BX SKN EA SEP/ADDL

Facility

$232.00

Service Code	HCPCS 11107
Hospital Charge Code	4853030
Hospital Revenue Code	761
Min. Negotiated Rate	$150.80
Max. Negotiated Rate	$150.80
Rate for Payer: Cash Price	$174.00
Rate for Payer: Galaxy Health Commercial	$150.80

INCAL BX SKN SINGLE LES

Facility

$2,265.00

Service Code	HCPCS 11106
Hospital Charge Code	4853029
Hospital Revenue Code	761
Min. Negotiated Rate	$339.75
Max. Negotiated Rate	$1,812.00
Rate for Payer: Aetna of NY Commercial	$1,585.50
Rate for Payer: Aetna of NY Medicare	$1,041.90
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$906.00
Rate for Payer: Cash Price	$1,698.75
Rate for Payer: CDPHP Medicare	$838.05
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$1,812.00
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$1,812.00
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$1,812.00
Rate for Payer: EmblemHealth Medicaid	$1,812.00
Rate for Payer: EmblemHealth Medicare	$770.10
Rate for Payer: EmblemHealth Select Care	$1,630.80
Rate for Payer: Fidelis Medicare	$906.00
Rate for Payer: Galaxy Health Commercial	$1,472.25
Rate for Payer: Hamaspik Choice Medicare	$906.00
Rate for Payer: Humana Medicare	$906.00
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$1,585.50
Rate for Payer: Local 1199SEIU Medicare	$1,041.90
Rate for Payer: MVP Health Care of NY Commercial	$1,698.75
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$1,275.19
Rate for Payer: MVP Health Care of NY Medicare	$951.30
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$339.75
Rate for Payer: United Healthcare Medicare	$906.00
Rate for Payer: WellCare Medicare	$1,245.75

INCAL BX SKN SINGLE LES

Facility

$2,265.00

Service Code	HCPCS 11106
Hospital Charge Code	4853029
Hospital Revenue Code	761
Min. Negotiated Rate	$1,472.25
Max. Negotiated Rate	$1,472.25
Rate for Payer: Cash Price	$1,698.75
Rate for Payer: Galaxy Health Commercial	$1,472.25

INC IMPLTJ NEUROSTIMULATOR ELTRD SACRAL NERVE

Facility

$19,689.00

Service Code	HCPCS 64581
Hospital Charge Code	4002011
Hospital Revenue Code	490
Min. Negotiated Rate	$12,797.85
Max. Negotiated Rate	$12,797.85
Rate for Payer: Cash Price	$14,766.75
Rate for Payer: Galaxy Health Commercial	$12,797.85

INC IMPLTJ NEUROSTIMULATOR ELTRD SACRAL NERVE

Facility

$19,689.00

Service Code	HCPCS 64581
Hospital Charge Code	4002011
Hospital Revenue Code	490
Min. Negotiated Rate	$1,900.00
Max. Negotiated Rate	$15,751.20
Rate for Payer: Aetna of NY Commercial	$1,900.00
Rate for Payer: Aetna of NY Medicare	$9,056.94
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$7,875.60
Rate for Payer: Cash Price	$14,766.75
Rate for Payer: Cash Price	$14,766.75
Rate for Payer: CDPHP Medicare	$7,284.93
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$15,751.20
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$15,751.20
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$15,751.20
Rate for Payer: EmblemHealth Medicaid	$15,751.20
Rate for Payer: EmblemHealth Medicare	$6,694.26
Rate for Payer: EmblemHealth Select Care	$14,176.08
Rate for Payer: Fidelis Medicare	$7,875.60
Rate for Payer: Galaxy Health Commercial	$12,797.85
Rate for Payer: Hamaspik Choice Medicare	$7,875.60
Rate for Payer: Humana Medicare	$7,875.60
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$1,900.00
Rate for Payer: Local 1199SEIU Medicare	$9,056.94
Rate for Payer: Multiplan Commercial	$15,751.20
Rate for Payer: MVP Health Care of NY Commercial	$14,766.75
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$11,084.91
Rate for Payer: MVP Health Care of NY Medicare	$8,269.38
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$2,373.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$2,953.35
Rate for Payer: United Healthcare Commercial	$2,373.00
Rate for Payer: United Healthcare Medicare	$7,875.60
Rate for Payer: WellCare Medicare	$10,828.95

INCISION&DRAINAGE BURSA FOOT

Facility

$5,062.00

Service Code	HCPCS 28001
Hospital Charge Code	4600157
Hospital Revenue Code	450
Min. Negotiated Rate	$759.30
Max. Negotiated Rate	$4,049.60
Rate for Payer: Aetna of NY Commercial	$1,000.00
Rate for Payer: Aetna of NY Medicare	$2,328.52
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$2,024.80
Rate for Payer: Cash Price	$3,796.50
Rate for Payer: Cash Price	$3,796.50
Rate for Payer: Cash Price	$3,796.50
Rate for Payer: CDPHP Medicare	$1,872.94
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$1,206.00
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$4,049.60
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$4,049.60
Rate for Payer: EmblemHealth Medicaid	$4,049.60
Rate for Payer: EmblemHealth Medicare	$1,721.08
Rate for Payer: EmblemHealth Select Care	$1,085.00
Rate for Payer: Fidelis Medicare	$2,024.80
Rate for Payer: Galaxy Health Commercial	$3,290.30
Rate for Payer: Hamaspik Choice Medicare	$2,024.80
Rate for Payer: Humana Medicare	$2,024.80
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$1,000.00
Rate for Payer: Local 1199SEIU Medicare	$2,328.52
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	$2,126.04
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$1,009.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$759.30
Rate for Payer: United Healthcare Commercial	$1,009.00
Rate for Payer: United Healthcare Medicare	$2,024.80
Rate for Payer: WellCare Medicare	$2,784.10

INCISION&DRAINAGE BURSA FOOT

Facility

$5,062.00

Service Code	HCPCS 28001
Hospital Charge Code	4600157
Hospital Revenue Code	450
Min. Negotiated Rate	$3,290.30
Max. Negotiated Rate	$3,290.30
Rate for Payer: Cash Price	$3,796.50
Rate for Payer: Galaxy Health Commercial	$3,290.30

INCISION, EXTENSOR TENDON SHEATH, WRIST (EG, DE QUERVAINS DISEASE)

Facility

$2,097.00

Service Code	CPT 25000
Hospital Revenue Code	490
Min. Negotiated Rate	$1,531.33
Max. Negotiated Rate	$2,097.00
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	$2,097.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$1,531.33
Rate for Payer: United Healthcare Commercial	$2,097.00

INCISION EXT THROMB HEMORRHOID

Facility

$766.00

Service Code	HCPCS 46083
Hospital Charge Code	4600112
Hospital Revenue Code	450
Min. Negotiated Rate	$497.90
Max. Negotiated Rate	$497.90
Rate for Payer: Cash Price	$574.50
Rate for Payer: Galaxy Health Commercial	$497.90

INCISION EXT THROMB HEMORRHOID

Facility

$766.00

Service Code	HCPCS 46083
Hospital Charge Code	4600112
Hospital Revenue Code	450
Min. Negotiated Rate	$114.90
Max. Negotiated Rate	$1,234.00
Rate for Payer: Aetna of NY Commercial	$1,000.00
Rate for Payer: Aetna of NY Medicare	$352.36
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$306.40
Rate for Payer: Cash Price	$574.50
Rate for Payer: Cash Price	$574.50
Rate for Payer: Cash Price	$574.50
Rate for Payer: CDPHP Medicare	$283.42
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$1,206.00
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$612.80
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$612.80
Rate for Payer: EmblemHealth Medicaid	$612.80
Rate for Payer: EmblemHealth Medicare	$260.44
Rate for Payer: EmblemHealth Select Care	$1,085.00
Rate for Payer: Fidelis Medicare	$306.40
Rate for Payer: Galaxy Health Commercial	$497.90
Rate for Payer: Hamaspik Choice Medicare	$306.40
Rate for Payer: Humana Medicare	$306.40
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$1,000.00
Rate for Payer: Local 1199SEIU Medicare	$352.36
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	$321.72
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$1,009.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$114.90
Rate for Payer: United Healthcare Commercial	$1,009.00
Rate for Payer: United Healthcare Medicare	$306.40
Rate for Payer: WellCare Medicare	$421.30

INC & REM FB SQ; COMPL

Facility

$5,062.00

Service Code	HCPCS 10121
Hospital Charge Code	4856683
Hospital Revenue Code	761
Min. Negotiated Rate	$759.30
Max. Negotiated Rate	$4,049.60
Rate for Payer: Aetna of NY Commercial	$3,543.40
Rate for Payer: Aetna of NY Medicare	$2,328.52
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$2,024.80
Rate for Payer: Cash Price	$3,796.50
Rate for Payer: CDPHP Medicare	$1,872.94
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$4,049.60
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$4,049.60
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$4,049.60
Rate for Payer: EmblemHealth Medicaid	$4,049.60
Rate for Payer: EmblemHealth Medicare	$1,721.08
Rate for Payer: EmblemHealth Select Care	$3,644.64
Rate for Payer: Fidelis Medicare	$2,024.80
Rate for Payer: Galaxy Health Commercial	$3,290.30
Rate for Payer: Hamaspik Choice Medicare	$2,024.80
Rate for Payer: Humana Medicare	$2,024.80
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$3,543.40
Rate for Payer: Local 1199SEIU Medicare	$2,328.52
Rate for Payer: MVP Health Care of NY Commercial	$3,796.50
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$2,849.91
Rate for Payer: MVP Health Care of NY Medicare	$2,126.04
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$759.30
Rate for Payer: United Healthcare Medicare	$2,024.80
Rate for Payer: WellCare Medicare	$2,784.10

INC & REM FB SQ; COMPL

Facility

$5,062.00

Service Code	HCPCS 10121
Hospital Charge Code	4856683
Hospital Revenue Code	761
Min. Negotiated Rate	$3,290.30
Max. Negotiated Rate	$3,290.30
Rate for Payer: Cash Price	$3,796.50
Rate for Payer: Galaxy Health Commercial	$3,290.30

INC & REM FB SQ; SMPL

Facility

$1,246.00

Service Code	HCPCS 10120
Hospital Charge Code	4856682
Hospital Revenue Code	761
Min. Negotiated Rate	$809.90
Max. Negotiated Rate	$809.90
Rate for Payer: Cash Price	$934.50
Rate for Payer: Galaxy Health Commercial	$809.90

INC & REM FB SQ; SMPL

Facility

$1,246.00

Service Code	HCPCS 10120
Hospital Charge Code	4856682
Hospital Revenue Code	761
Min. Negotiated Rate	$186.90
Max. Negotiated Rate	$996.80
Rate for Payer: Aetna of NY Commercial	$872.20
Rate for Payer: Aetna of NY Medicare	$573.16
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$498.40
Rate for Payer: Cash Price	$934.50
Rate for Payer: CDPHP Medicare	$461.02
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$996.80
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$996.80
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$996.80
Rate for Payer: EmblemHealth Medicaid	$996.80
Rate for Payer: EmblemHealth Medicare	$423.64
Rate for Payer: EmblemHealth Select Care	$897.12
Rate for Payer: Fidelis Medicare	$498.40
Rate for Payer: Galaxy Health Commercial	$809.90
Rate for Payer: Hamaspik Choice Medicare	$498.40
Rate for Payer: Humana Medicare	$498.40
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$872.20
Rate for Payer: Local 1199SEIU Medicare	$573.16
Rate for Payer: MVP Health Care of NY Commercial	$934.50
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$701.50
Rate for Payer: MVP Health Care of NY Medicare	$523.32
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$186.90
Rate for Payer: United Healthcare Medicare	$498.40
Rate for Payer: WellCare Medicare	$685.30

INC/REM FOR BODY SUBCUT SIMPLE

Facility

$1,246.00

Service Code	HCPCS 10120
Hospital Charge Code	4600111
Hospital Revenue Code	450
Min. Negotiated Rate	$809.90
Max. Negotiated Rate	$809.90
Rate for Payer: Cash Price	$934.50
Rate for Payer: Galaxy Health Commercial	$809.90

INC/REM FOR BODY SUBCUT SIMPLE

Facility

$1,246.00

Service Code	HCPCS 10120
Hospital Charge Code	4600111
Hospital Revenue Code	450
Min. Negotiated Rate	$186.90
Max. Negotiated Rate	$1,234.00
Rate for Payer: Aetna of NY Commercial	$1,000.00
Rate for Payer: Aetna of NY Medicare	$573.16
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$498.40
Rate for Payer: Cash Price	$934.50
Rate for Payer: Cash Price	$934.50
Rate for Payer: Cash Price	$934.50
Rate for Payer: CDPHP Medicare	$461.02
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$1,206.00
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$996.80
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$996.80
Rate for Payer: EmblemHealth Medicaid	$996.80
Rate for Payer: EmblemHealth Medicare	$423.64
Rate for Payer: EmblemHealth Select Care	$1,085.00
Rate for Payer: Fidelis Medicare	$498.40
Rate for Payer: Galaxy Health Commercial	$809.90
Rate for Payer: Hamaspik Choice Medicare	$498.40
Rate for Payer: Humana Medicare	$498.40
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$1,000.00
Rate for Payer: Local 1199SEIU Medicare	$573.16
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	$523.32
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$1,009.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$186.90
Rate for Payer: United Healthcare Commercial	$1,009.00
Rate for Payer: United Healthcare Medicare	$498.40
Rate for Payer: WellCare Medicare	$685.30

Know your out-of-pocket cost for care.

All Charges