Ellenville Regional Hospital

All Charges

Charge

Type

Setting

Price

LAP PLACE GASTR ADJ DEVICE

Facility

$32,580.00

Service Code	HCPCS 43770
Hospital Charge Code	4001001
Hospital Revenue Code	490
Min. Negotiated Rate	$1,900.00
Max. Negotiated Rate	$26,064.00
Rate for Payer: Aetna of NY Commercial	$1,900.00
Rate for Payer: Aetna of NY Medicare	$14,986.80
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$13,032.00
Rate for Payer: Cash Price	$24,435.00
Rate for Payer: Cash Price	$24,435.00
Rate for Payer: CDPHP Medicare	$12,054.60
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$26,064.00
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$26,064.00
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$26,064.00
Rate for Payer: EmblemHealth Medicaid	$26,064.00
Rate for Payer: EmblemHealth Medicare	$11,077.20
Rate for Payer: EmblemHealth Select Care	$23,457.60
Rate for Payer: Fidelis Medicare	$13,032.00
Rate for Payer: Galaxy Health Commercial	$21,177.00
Rate for Payer: Hamaspik Choice Medicare	$13,032.00
Rate for Payer: Humana Medicare	$13,032.00
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$1,900.00
Rate for Payer: Local 1199SEIU Medicare	$14,986.80
Rate for Payer: Multiplan Commercial	$26,064.00
Rate for Payer: MVP Health Care of NY Commercial	$24,435.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$18,342.54
Rate for Payer: MVP Health Care of NY Medicare	$13,683.60
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$2,373.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$4,887.00
Rate for Payer: United Healthcare Commercial	$2,373.00
Rate for Payer: United Healthcare Medicare	$13,032.00
Rate for Payer: WellCare Medicare	$17,919.00

LAP PLACE GASTR ADJ DEVICE

Facility

$32,580.00

Service Code	HCPCS 43770
Hospital Charge Code	4001001
Hospital Revenue Code	490
Min. Negotiated Rate	$21,177.00
Max. Negotiated Rate	$21,177.00
Rate for Payer: Cash Price	$24,435.00
Rate for Payer: Galaxy Health Commercial	$21,177.00

LARGE LEFT COMFORTFORM WRIST

Facility

$27.81

Hospital Charge Code	4471572
Hospital Revenue Code	270
Min. Negotiated Rate	$4.17
Max. Negotiated Rate	$22.25
Rate for Payer: Aetna of NY Commercial	$19.47
Rate for Payer: Aetna of NY Medicare	$12.79
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$11.12
Rate for Payer: Cash Price	$20.86
Rate for Payer: CDPHP Medicare	$10.29
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$22.25
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$22.25
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$22.25
Rate for Payer: EmblemHealth Medicaid	$22.25
Rate for Payer: EmblemHealth Medicare	$9.46
Rate for Payer: EmblemHealth Select Care	$20.02
Rate for Payer: Fidelis Medicare	$11.12
Rate for Payer: Galaxy Health Commercial	$18.08
Rate for Payer: Hamaspik Choice Medicare	$11.12
Rate for Payer: Humana Medicare	$11.12
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$19.47
Rate for Payer: Local 1199SEIU Medicare	$12.79
Rate for Payer: MVP Health Care of NY Commercial	$20.86
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$15.66
Rate for Payer: MVP Health Care of NY Medicare	$11.68
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$4.17
Rate for Payer: United Healthcare Medicare	$11.12
Rate for Payer: WellCare Medicare	$15.30

LARGE LEFT COMFORTFORM WRIST

Facility

$27.81

Hospital Charge Code	4471572
Hospital Revenue Code	270
Min. Negotiated Rate	$18.08
Max. Negotiated Rate	$18.08
Rate for Payer: Cash Price	$20.86
Rate for Payer: Galaxy Health Commercial	$18.08

LARGE RIGHT COMFORTFORM WRIST

Facility

$27.81

Hospital Charge Code	4471567
Hospital Revenue Code	270
Min. Negotiated Rate	$18.08
Max. Negotiated Rate	$18.08
Rate for Payer: Cash Price	$20.86
Rate for Payer: Galaxy Health Commercial	$18.08

LARGE RIGHT COMFORTFORM WRIST

Facility

$27.81

Hospital Charge Code	4471567
Hospital Revenue Code	270
Min. Negotiated Rate	$4.17
Max. Negotiated Rate	$22.25
Rate for Payer: Aetna of NY Commercial	$19.47
Rate for Payer: Aetna of NY Medicare	$12.79
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$11.12
Rate for Payer: Cash Price	$20.86
Rate for Payer: CDPHP Medicare	$10.29
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$22.25
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$22.25
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$22.25
Rate for Payer: EmblemHealth Medicaid	$22.25
Rate for Payer: EmblemHealth Medicare	$9.46
Rate for Payer: EmblemHealth Select Care	$20.02
Rate for Payer: Fidelis Medicare	$11.12
Rate for Payer: Galaxy Health Commercial	$18.08
Rate for Payer: Hamaspik Choice Medicare	$11.12
Rate for Payer: Humana Medicare	$11.12
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$19.47
Rate for Payer: Local 1199SEIU Medicare	$12.79
Rate for Payer: MVP Health Care of NY Commercial	$20.86
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$15.66
Rate for Payer: MVP Health Care of NY Medicare	$11.68
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$4.17
Rate for Payer: United Healthcare Medicare	$11.12
Rate for Payer: WellCare Medicare	$15.30

LARGE SPECIALTY ARM SLING

Facility

$14.42

Service Code	HCPCS A4566
Hospital Charge Code	4471558
Hospital Revenue Code	270
Min. Negotiated Rate	$9.37
Max. Negotiated Rate	$9.37
Rate for Payer: Cash Price	$10.82
Rate for Payer: Galaxy Health Commercial	$9.37

LARGE SPECIALTY ARM SLING

Facility

$14.42

Service Code	HCPCS A4566
Hospital Charge Code	4471558
Hospital Revenue Code	270
Min. Negotiated Rate	$2.16
Max. Negotiated Rate	$11.54
Rate for Payer: Aetna of NY Commercial	$10.09
Rate for Payer: Aetna of NY Medicare	$6.63
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$5.77
Rate for Payer: Cash Price	$10.82
Rate for Payer: CDPHP Medicare	$5.34
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$11.54
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$11.54
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$11.54
Rate for Payer: EmblemHealth Medicaid	$11.54
Rate for Payer: EmblemHealth Medicare	$4.90
Rate for Payer: EmblemHealth Select Care	$10.38
Rate for Payer: Fidelis Medicare	$5.77
Rate for Payer: Galaxy Health Commercial	$9.37
Rate for Payer: Hamaspik Choice Medicare	$5.77
Rate for Payer: Humana Medicare	$5.77
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$10.09
Rate for Payer: Local 1199SEIU Medicare	$6.63
Rate for Payer: MVP Health Care of NY Commercial	$10.81
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$8.12
Rate for Payer: MVP Health Care of NY Medicare	$6.06
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$2.16
Rate for Payer: United Healthcare Medicare	$5.77
Rate for Payer: WellCare Medicare	$7.93

LARGE STOCKING ANTI-EMB THIGH

Facility

$19.57

Hospital Charge Code	4471186
Hospital Revenue Code	270
Min. Negotiated Rate	$12.72
Max. Negotiated Rate	$12.72
Rate for Payer: Cash Price	$14.68
Rate for Payer: Galaxy Health Commercial	$12.72

LARGE STOCKING ANTI-EMB THIGH

Facility

$19.57

Hospital Charge Code	4471186
Hospital Revenue Code	270
Min. Negotiated Rate	$2.94
Max. Negotiated Rate	$15.66
Rate for Payer: Aetna of NY Commercial	$13.70
Rate for Payer: Aetna of NY Medicare	$9.00
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$7.83
Rate for Payer: Cash Price	$14.68
Rate for Payer: CDPHP Medicare	$7.24
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$15.66
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$15.66
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$15.66
Rate for Payer: EmblemHealth Medicaid	$15.66
Rate for Payer: EmblemHealth Medicare	$6.65
Rate for Payer: EmblemHealth Select Care	$14.09
Rate for Payer: Fidelis Medicare	$7.83
Rate for Payer: Galaxy Health Commercial	$12.72
Rate for Payer: Hamaspik Choice Medicare	$7.83
Rate for Payer: Humana Medicare	$7.83
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$13.70
Rate for Payer: Local 1199SEIU Medicare	$9.00
Rate for Payer: MVP Health Care of NY Commercial	$14.68
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$11.02
Rate for Payer: MVP Health Care of NY Medicare	$8.22
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$2.94
Rate for Payer: United Healthcare Medicare	$7.83
Rate for Payer: WellCare Medicare	$10.76

LASER VAPORIZATION OF PROSTATE FOR URINE FLOW

Facility

$16,434.00

Service Code	HCPCS 52648
Hospital Charge Code	4002031
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

LASER VAPORIZATION OF PROSTATE FOR URINE FLOW

Facility

$16,434.00

Service Code	HCPCS 52648
Hospital Charge Code	4002031
Hospital Revenue Code	490
Min. Negotiated Rate	$1,900.00
Max. Negotiated Rate	$13,147.20
Rate for Payer: Aetna of NY Commercial	$1,900.00
Rate for Payer: Aetna of NY Medicare	$7,559.64
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$6,573.60
Rate for Payer: Cash Price	$12,325.50
Rate for Payer: Cash Price	$12,325.50
Rate for Payer: CDPHP Medicare	$6,080.58
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$13,147.20
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$13,147.20
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$13,147.20
Rate for Payer: EmblemHealth Medicaid	$13,147.20
Rate for Payer: EmblemHealth Medicare	$5,587.56
Rate for Payer: EmblemHealth Select Care	$11,832.48
Rate for Payer: Fidelis Medicare	$6,573.60
Rate for Payer: Galaxy Health Commercial	$10,682.10
Rate for Payer: Hamaspik Choice Medicare	$6,573.60
Rate for Payer: Humana Medicare	$6,573.60
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$1,900.00
Rate for Payer: Local 1199SEIU Medicare	$7,559.64
Rate for Payer: Multiplan Commercial	$13,147.20
Rate for Payer: MVP Health Care of NY Commercial	$12,325.50
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$9,252.34
Rate for Payer: MVP Health Care of NY Medicare	$6,902.28
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$2,097.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$2,465.10
Rate for Payer: United Healthcare Commercial	$2,097.00
Rate for Payer: United Healthcare Medicare	$6,573.60
Rate for Payer: WellCare Medicare	$9,038.70

LATANOPROST 0.00005 DROP 3X2.5ML

Facility

$293.55

Service Code	NDC 61314054701
Hospital Charge Code	4400812
Hospital Revenue Code	250
Min. Negotiated Rate	$161.45
Max. Negotiated Rate	$190.81
Rate for Payer: Cash Price	$220.16
Rate for Payer: Galaxy Health Commercial	$190.81
Rate for Payer: WellCare Medicare	$161.45

LATANOPROST 0.00005 DROP 3X2.5ML

Facility

$293.55

Service Code	NDC 61314054701
Hospital Charge Code	4400812
Hospital Revenue Code	250
Min. Negotiated Rate	$44.03
Max. Negotiated Rate	$234.84
Rate for Payer: Aetna of NY Commercial	$205.49
Rate for Payer: Aetna of NY Medicare	$135.03
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$117.42
Rate for Payer: Cash Price	$220.16
Rate for Payer: CDPHP Medicare	$108.61
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$234.84
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$234.84
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$234.84
Rate for Payer: EmblemHealth Medicaid	$234.84
Rate for Payer: EmblemHealth Medicare	$99.81
Rate for Payer: EmblemHealth Select Care	$211.36
Rate for Payer: Fidelis Medicare	$117.42
Rate for Payer: Galaxy Health Commercial	$190.81
Rate for Payer: Hamaspik Choice Medicare	$117.42
Rate for Payer: Humana Medicare	$117.42
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$205.49
Rate for Payer: Local 1199SEIU Medicare	$135.03
Rate for Payer: MVP Health Care of NY Commercial	$220.16
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$165.27
Rate for Payer: MVP Health Care of NY Medicare	$123.29
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$44.03
Rate for Payer: United Healthcare Medicare	$117.42
Rate for Payer: WellCare Medicare	$161.45

LAYER CLOSURE-12.6 TO 20CM

Facility

$2,265.00

Service Code	HCPCS 12045
Hospital Charge Code	4600119
Hospital Revenue Code	450
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

LAYER CLOSURE-12.6 TO 20CM

Facility

$2,265.00

Service Code	HCPCS 12045
Hospital Charge Code	4600119
Hospital Revenue Code	450
Min. Negotiated Rate	$339.75
Max. Negotiated Rate	$1,812.00
Rate for Payer: Aetna of NY Commercial	$1,000.00
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: Cash Price	$1,698.75
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	$1,206.00
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	$1,085.00
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	$1,000.00
Rate for Payer: Local 1199SEIU Medicare	$1,041.90
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	$951.30
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$1,009.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$339.75
Rate for Payer: United Healthcare Commercial	$1,009.00
Rate for Payer: United Healthcare Medicare	$906.00
Rate for Payer: WellCare Medicare	$1,245.75

LAYER CLOSURE-20.1 TO 30.0CM

Facility

$1,246.00

Service Code	HCPCS 12056
Hospital Charge Code	4600124
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

LAYER CLOSURE-20.1 TO 30.0CM

Facility

$1,246.00

Service Code	HCPCS 12056
Hospital Charge Code	4600124
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

LAYER CLOSURE-2.5 CM OR LESS

Facility

$1,246.00

Service Code	HCPCS 12031
Hospital Charge Code	4600120
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

LAYER CLOSURE-2.5 CM OR LESS

Facility

$1,246.00

Service Code	HCPCS 12031
Hospital Charge Code	4600120
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

LAYER CLOSURE-2.5CM OR LESS

Facility

$1,246.00

Service Code	HCPCS 12041
Hospital Charge Code	4600131
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

LAYER CLOSURE-2.5CM OR LESS

Facility

$1,246.00

Service Code	HCPCS 12041
Hospital Charge Code	4600131
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

LAYER CLOSURE-2.6 TO 5.0CM

Facility

$1,246.00

Service Code	HCPCS 12052
Hospital Charge Code	4600121
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

LAYER CLOSURE-2.6 TO 5.0CM

Facility

$1,246.00

Service Code	HCPCS 12052
Hospital Charge Code	4600121
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

LAYER CLOSURE-2.6 TO 7.5CM

Facility

$1,246.00

Service Code	HCPCS 12032
Hospital Charge Code	4600122
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

Know your out-of-pocket cost for care.

All Charges