Ellenville Regional Hospital

All Charges

Charge

Type

Setting

Price

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

LAYER CLOSURE-7.6 TO 12.5CM

Facility

$1,246.00

Service Code	HCPCS 12034
Hospital Charge Code	4600128
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-7.6 TO 12.5CM

Facility

$1,246.00

Service Code	HCPCS 12034
Hospital Charge Code	4600128
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

LDH

Facility

$18.00

Service Code	HCPCS 83615
Hospital Charge Code	4300514
Hospital Revenue Code	301
Min. Negotiated Rate	$2.70
Max. Negotiated Rate	$14.40
Rate for Payer: Aetna of NY Commercial	$11.70
Rate for Payer: Aetna of NY Medicare	$8.28
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$7.20
Rate for Payer: Cash Price	$13.50
Rate for Payer: CDPHP Medicare	$6.66
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$10.80
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$14.40
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$14.40
Rate for Payer: EmblemHealth Medicaid	$14.40
Rate for Payer: EmblemHealth Medicare	$6.12
Rate for Payer: EmblemHealth Select Care	$10.80
Rate for Payer: Fidelis Medicare	$7.20
Rate for Payer: Galaxy Health Commercial	$11.70
Rate for Payer: Hamaspik Choice Medicare	$7.20
Rate for Payer: Humana Medicare	$7.20
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$11.70
Rate for Payer: Local 1199SEIU Medicare	$8.28
Rate for Payer: MVP Health Care of NY Commercial	$13.50
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$10.13
Rate for Payer: MVP Health Care of NY Medicare	$7.56
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$13.50
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$2.70
Rate for Payer: United Healthcare Commercial	$13.50
Rate for Payer: United Healthcare Medicare	$7.20
Rate for Payer: WellCare Medicare	$9.90

LDH

Facility

$18.00

Service Code	HCPCS 83615
Hospital Charge Code	4300514
Hospital Revenue Code	301
Min. Negotiated Rate	$11.70
Max. Negotiated Rate	$11.70
Rate for Payer: Cash Price	$13.50
Rate for Payer: Galaxy Health Commercial	$11.70

LEAD KITS

Facility

$9,215.41

Service Code	HCPCS C1778
Hospital Charge Code	4471319
Hospital Revenue Code	278
Min. Negotiated Rate	$1,382.31
Max. Negotiated Rate	$7,372.33
Rate for Payer: Aetna of NY Commercial	$6,450.79
Rate for Payer: Aetna of NY Medicare	$4,239.09
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$3,686.16
Rate for Payer: Cash Price	$6,911.56
Rate for Payer: CDPHP Medicare	$3,409.70
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$4,607.70
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$7,372.33
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$7,372.33
Rate for Payer: EmblemHealth Medicaid	$7,372.33
Rate for Payer: EmblemHealth Medicare	$3,133.24
Rate for Payer: EmblemHealth Select Care	$4,607.70
Rate for Payer: Fidelis Medicare	$3,686.16
Rate for Payer: Galaxy Health Commercial	$5,990.02
Rate for Payer: Hamaspik Choice Medicare	$3,686.16
Rate for Payer: Humana Medicare	$3,686.16
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$6,450.79
Rate for Payer: Local 1199SEIU Medicare	$4,239.09
Rate for Payer: MVP Health Care of NY Commercial	$5,990.02
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$5,990.02
Rate for Payer: MVP Health Care of NY Medicare	$3,870.47
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$1,382.31
Rate for Payer: United Healthcare Medicare	$3,686.16
Rate for Payer: WellCare Medicare	$5,068.48

LEAD KITS

Facility

$9,215.41

Service Code	HCPCS C1778
Hospital Charge Code	4471319
Hospital Revenue Code	278
Min. Negotiated Rate	$4,146.93
Max. Negotiated Rate	$6,450.79
Rate for Payer: Aetna of NY Commercial	$6,450.79
Rate for Payer: Cash Price	$6,911.56
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$4,607.70
Rate for Payer: EmblemHealth Select Care	$4,607.70
Rate for Payer: Galaxy Health Commercial	$5,990.02
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$6,450.79
Rate for Payer: Multiplan Commercial	$4,146.93
Rate for Payer: MVP Health Care of NY Commercial	$5,990.02
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$5,990.02
Rate for Payer: WellCare Medicare	$5,068.48

LEFLUNOMIDE 10 MG TABLET 10 mg, 30 eaches

Facility

$50.00

Service Code	NDC 23155004303
Hospital Charge Code	4401393
Hospital Revenue Code	250
Min. Negotiated Rate	$27.50
Max. Negotiated Rate	$32.50
Rate for Payer: Cash Price	$37.50
Rate for Payer: Galaxy Health Commercial	$32.50
Rate for Payer: WellCare Medicare	$27.50

LEFLUNOMIDE 10 MG TABLET 10 mg, 30 eaches

Facility

$50.00

Service Code	NDC 23155004303
Hospital Charge Code	4401393
Hospital Revenue Code	250
Min. Negotiated Rate	$7.50
Max. Negotiated Rate	$40.00
Rate for Payer: Aetna of NY Commercial	$35.00
Rate for Payer: Aetna of NY Medicare	$23.00
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$20.00
Rate for Payer: Cash Price	$37.50
Rate for Payer: CDPHP Medicare	$18.50
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$40.00
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$40.00
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$40.00
Rate for Payer: EmblemHealth Medicaid	$40.00
Rate for Payer: EmblemHealth Medicare	$17.00
Rate for Payer: EmblemHealth Select Care	$36.00
Rate for Payer: Fidelis Medicare	$20.00
Rate for Payer: Galaxy Health Commercial	$32.50
Rate for Payer: Hamaspik Choice Medicare	$20.00
Rate for Payer: Humana Medicare	$20.00
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$35.00
Rate for Payer: Local 1199SEIU Medicare	$23.00
Rate for Payer: MVP Health Care of NY Commercial	$37.50
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$28.15
Rate for Payer: MVP Health Care of NY Medicare	$21.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$7.50
Rate for Payer: United Healthcare Medicare	$20.00
Rate for Payer: WellCare Medicare	$27.50

LEFLUNOMIDE 20 MG (GENERIC ARAVA ) TABL

Facility

$50.73

Service Code	NDC 955173730
Hospital Charge Code	4409204
Hospital Revenue Code	250
Min. Negotiated Rate	$7.61
Max. Negotiated Rate	$40.58
Rate for Payer: Aetna of NY Commercial	$35.51
Rate for Payer: Aetna of NY Medicare	$23.34
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$20.29
Rate for Payer: Cash Price	$38.05
Rate for Payer: CDPHP Medicare	$18.77
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$40.58
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$40.58
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$40.58
Rate for Payer: EmblemHealth Medicaid	$40.58
Rate for Payer: EmblemHealth Medicare	$17.25
Rate for Payer: EmblemHealth Select Care	$36.53
Rate for Payer: Fidelis Medicare	$20.29
Rate for Payer: Galaxy Health Commercial	$32.97
Rate for Payer: Hamaspik Choice Medicare	$20.29
Rate for Payer: Humana Medicare	$20.29
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$35.51
Rate for Payer: Local 1199SEIU Medicare	$23.34
Rate for Payer: MVP Health Care of NY Commercial	$38.05
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$28.56
Rate for Payer: MVP Health Care of NY Medicare	$21.31
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$7.61
Rate for Payer: United Healthcare Medicare	$20.29
Rate for Payer: WellCare Medicare	$27.90

LEFLUNOMIDE 20 MG (GENERIC ARAVA ) TABL

Facility

$50.73

Service Code	NDC 955173730
Hospital Charge Code	4409204
Hospital Revenue Code	250
Min. Negotiated Rate	$27.90
Max. Negotiated Rate	$32.97
Rate for Payer: Cash Price	$38.05
Rate for Payer: Galaxy Health Commercial	$32.97
Rate for Payer: WellCare Medicare	$27.90

LEGIONELLA P AG BY DFA

Facility

$47.00

Service Code	HCPCS 87278
Hospital Charge Code	4301257
Hospital Revenue Code	306
Min. Negotiated Rate	$30.55
Max. Negotiated Rate	$30.55
Rate for Payer: Cash Price	$35.25
Rate for Payer: Galaxy Health Commercial	$30.55

LEGIONELLA P AG BY DFA

Facility

$47.00

Service Code	HCPCS 87278
Hospital Charge Code	4301257
Hospital Revenue Code	306
Min. Negotiated Rate	$7.05
Max. Negotiated Rate	$37.60
Rate for Payer: Aetna of NY Commercial	$30.55
Rate for Payer: Aetna of NY Medicare	$21.62
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$18.80
Rate for Payer: Cash Price	$35.25
Rate for Payer: CDPHP Medicare	$17.39
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$28.20
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$37.60
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$37.60
Rate for Payer: EmblemHealth Medicaid	$37.60
Rate for Payer: EmblemHealth Medicare	$15.98
Rate for Payer: EmblemHealth Select Care	$28.20
Rate for Payer: Fidelis Medicare	$18.80
Rate for Payer: Galaxy Health Commercial	$30.55
Rate for Payer: Hamaspik Choice Medicare	$18.80
Rate for Payer: Humana Medicare	$18.80
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$30.55
Rate for Payer: Local 1199SEIU Medicare	$21.62
Rate for Payer: MVP Health Care of NY Commercial	$35.25
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$26.46
Rate for Payer: MVP Health Care of NY Medicare	$19.74
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$35.25
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$7.05
Rate for Payer: United Healthcare Commercial	$35.25
Rate for Payer: United Healthcare Medicare	$18.80
Rate for Payer: WellCare Medicare	$25.85

LESIONHUNTER COLD SNARE, OVAL 10 MM WIDE, NITINOL WIRE

Facility

$50.00

Hospital Charge Code	4473054
Hospital Revenue Code	272
Min. Negotiated Rate	$32.50
Max. Negotiated Rate	$32.50
Rate for Payer: Cash Price	$37.50
Rate for Payer: Galaxy Health Commercial	$32.50

LESIONHUNTER COLD SNARE, OVAL 10 MM WIDE, NITINOL WIRE

Facility

$50.00

Hospital Charge Code	4473054
Hospital Revenue Code	272
Min. Negotiated Rate	$7.50
Max. Negotiated Rate	$40.00
Rate for Payer: Aetna of NY Commercial	$35.00
Rate for Payer: Aetna of NY Medicare	$23.00
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$20.00
Rate for Payer: Cash Price	$37.50
Rate for Payer: CDPHP Medicare	$18.50
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$40.00
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$40.00
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$40.00
Rate for Payer: EmblemHealth Medicaid	$40.00
Rate for Payer: EmblemHealth Medicare	$17.00
Rate for Payer: EmblemHealth Select Care	$36.00
Rate for Payer: Fidelis Medicare	$20.00
Rate for Payer: Galaxy Health Commercial	$32.50
Rate for Payer: Hamaspik Choice Medicare	$20.00
Rate for Payer: Humana Medicare	$20.00
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$35.00
Rate for Payer: Local 1199SEIU Medicare	$23.00
Rate for Payer: MVP Health Care of NY Commercial	$37.50
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$28.15
Rate for Payer: MVP Health Care of NY Medicare	$21.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$7.50
Rate for Payer: United Healthcare Medicare	$20.00
Rate for Payer: WellCare Medicare	$27.50

LETROZOLE 2.5MG TABS 30 EA

Facility

$55.88

Service Code	NDC 16729003410
Hospital Charge Code	4400423
Hospital Revenue Code	250
Min. Negotiated Rate	$30.73
Max. Negotiated Rate	$36.32
Rate for Payer: Cash Price	$41.91
Rate for Payer: Galaxy Health Commercial	$36.32
Rate for Payer: WellCare Medicare	$30.73

LETROZOLE 2.5MG TABS 30 EA

Facility

$55.88

Service Code	NDC 16729003410
Hospital Charge Code	4400423
Hospital Revenue Code	250
Min. Negotiated Rate	$8.38
Max. Negotiated Rate	$44.70
Rate for Payer: Aetna of NY Commercial	$39.12
Rate for Payer: Aetna of NY Medicare	$25.70
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$22.35
Rate for Payer: Cash Price	$41.91
Rate for Payer: CDPHP Medicare	$20.68
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$44.70
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$44.70
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$44.70
Rate for Payer: EmblemHealth Medicaid	$44.70
Rate for Payer: EmblemHealth Medicare	$19.00
Rate for Payer: EmblemHealth Select Care	$40.23
Rate for Payer: Fidelis Medicare	$22.35
Rate for Payer: Galaxy Health Commercial	$36.32
Rate for Payer: Hamaspik Choice Medicare	$22.35
Rate for Payer: Humana Medicare	$22.35
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$39.12
Rate for Payer: Local 1199SEIU Medicare	$25.70
Rate for Payer: MVP Health Care of NY Commercial	$41.91
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$31.46
Rate for Payer: MVP Health Care of NY Medicare	$23.47
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$8.38
Rate for Payer: United Healthcare Medicare	$22.35
Rate for Payer: WellCare Medicare	$30.73

LEUKOCYTE ASSMT FECAL QUAL/SEMIQUANTITATIVE

Facility

$15.00

Service Code	HCPCS 89055
Hospital Charge Code	4302016
Hospital Revenue Code	300
Min. Negotiated Rate	$9.75
Max. Negotiated Rate	$9.75
Rate for Payer: Cash Price	$11.25
Rate for Payer: Galaxy Health Commercial	$9.75

LEUKOCYTE ASSMT FECAL QUAL/SEMIQUANTITATIVE

Facility

$15.00

Service Code	HCPCS 89055
Hospital Charge Code	4302016
Hospital Revenue Code	300
Min. Negotiated Rate	$2.25
Max. Negotiated Rate	$12.00
Rate for Payer: Aetna of NY Commercial	$9.75
Rate for Payer: Aetna of NY Medicare	$6.90
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$6.00
Rate for Payer: Cash Price	$11.25
Rate for Payer: CDPHP Medicare	$5.55
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$9.00
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$12.00
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$12.00
Rate for Payer: EmblemHealth Medicaid	$12.00
Rate for Payer: EmblemHealth Medicare	$5.10
Rate for Payer: EmblemHealth Select Care	$9.00
Rate for Payer: Fidelis Medicare	$6.00
Rate for Payer: Galaxy Health Commercial	$9.75
Rate for Payer: Hamaspik Choice Medicare	$6.00
Rate for Payer: Humana Medicare	$6.00
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$9.75
Rate for Payer: Local 1199SEIU Medicare	$6.90
Rate for Payer: MVP Health Care of NY Commercial	$11.25
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$8.45
Rate for Payer: MVP Health Care of NY Medicare	$6.30
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$11.25
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$2.25
Rate for Payer: United Healthcare Commercial	$11.25
Rate for Payer: United Healthcare Medicare	$6.00
Rate for Payer: WellCare Medicare	$8.25

LEUKO REDUCED PLATELETS EA UNIT

Facility

$433.00

Service Code	HCPCS P9031
Hospital Charge Code	4302357
Hospital Revenue Code	390
Min. Negotiated Rate	$64.95
Max. Negotiated Rate	$346.40
Rate for Payer: Aetna of NY Commercial	$303.10
Rate for Payer: Aetna of NY Medicare	$199.18
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$173.20
Rate for Payer: Cash Price	$324.75
Rate for Payer: CDPHP Medicare	$160.21
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$216.50
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$346.40
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$346.40
Rate for Payer: EmblemHealth Medicaid	$346.40
Rate for Payer: EmblemHealth Medicare	$147.22
Rate for Payer: EmblemHealth Select Care	$216.50
Rate for Payer: Fidelis Medicare	$173.20
Rate for Payer: Galaxy Health Commercial	$281.45
Rate for Payer: Hamaspik Choice Medicare	$173.20
Rate for Payer: Humana Medicare	$173.20
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$303.10
Rate for Payer: Local 1199SEIU Medicare	$199.18
Rate for Payer: MVP Health Care of NY Commercial	$324.75
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$243.78
Rate for Payer: MVP Health Care of NY Medicare	$181.86
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$324.75
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$64.95
Rate for Payer: United Healthcare Commercial	$324.75
Rate for Payer: United Healthcare Medicare	$173.20
Rate for Payer: WellCare Medicare	$238.15

LEUKO REDUCED PLATELETS EA UNIT

Facility

$433.00

Service Code	HCPCS P9031
Hospital Charge Code	4302357
Hospital Revenue Code	390
Min. Negotiated Rate	$216.50
Max. Negotiated Rate	$281.45
Rate for Payer: Cash Price	$324.75
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$216.50
Rate for Payer: EmblemHealth Select Care	$216.50
Rate for Payer: Galaxy Health Commercial	$281.45
Rate for Payer: WellCare Medicare	$238.15

LEUKOREDUCED RBC

Facility

$555.00

Service Code	HCPCS P9016
Hospital Charge Code	4300526
Hospital Revenue Code	390
Min. Negotiated Rate	$83.25
Max. Negotiated Rate	$444.00
Rate for Payer: Aetna of NY Commercial	$388.50
Rate for Payer: Aetna of NY Medicare	$255.30
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$222.00
Rate for Payer: Cash Price	$416.25
Rate for Payer: CDPHP Medicare	$205.35
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$277.50
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$444.00
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$444.00
Rate for Payer: EmblemHealth Medicaid	$444.00
Rate for Payer: EmblemHealth Medicare	$188.70
Rate for Payer: EmblemHealth Select Care	$277.50
Rate for Payer: Fidelis Medicare	$222.00
Rate for Payer: Galaxy Health Commercial	$360.75
Rate for Payer: Hamaspik Choice Medicare	$222.00
Rate for Payer: Humana Medicare	$222.00
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$388.50
Rate for Payer: Local 1199SEIU Medicare	$255.30
Rate for Payer: MVP Health Care of NY Commercial	$416.25
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$312.46
Rate for Payer: MVP Health Care of NY Medicare	$233.10
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$416.25
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$83.25
Rate for Payer: United Healthcare Commercial	$416.25
Rate for Payer: United Healthcare Medicare	$222.00
Rate for Payer: WellCare Medicare	$305.25

LEUKOREDUCED RBC

Facility

$555.00

Service Code	HCPCS P9016
Hospital Charge Code	4300526
Hospital Revenue Code	390
Min. Negotiated Rate	$277.50
Max. Negotiated Rate	$360.75
Rate for Payer: Cash Price	$416.25
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$277.50
Rate for Payer: EmblemHealth Select Care	$277.50
Rate for Payer: Galaxy Health Commercial	$360.75
Rate for Payer: WellCare Medicare	$305.25

LEUKOTAPE 1.5" X 15 YDS

Facility

$42.23

Hospital Charge Code	4471451
Hospital Revenue Code	270
Min. Negotiated Rate	$27.45
Max. Negotiated Rate	$27.45
Rate for Payer: Cash Price	$31.67
Rate for Payer: Galaxy Health Commercial	$27.45

LEUKOTAPE 1.5" X 15 YDS

Facility

$42.23

Hospital Charge Code	4471451
Hospital Revenue Code	270
Min. Negotiated Rate	$6.33
Max. Negotiated Rate	$33.78
Rate for Payer: Aetna of NY Commercial	$29.56
Rate for Payer: Aetna of NY Medicare	$19.43
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$16.89
Rate for Payer: Cash Price	$31.67
Rate for Payer: CDPHP Medicare	$15.63
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$33.78
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$33.78
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$33.78
Rate for Payer: EmblemHealth Medicaid	$33.78
Rate for Payer: EmblemHealth Medicare	$14.36
Rate for Payer: EmblemHealth Select Care	$30.41
Rate for Payer: Fidelis Medicare	$16.89
Rate for Payer: Galaxy Health Commercial	$27.45
Rate for Payer: Hamaspik Choice Medicare	$16.89
Rate for Payer: Humana Medicare	$16.89
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$29.56
Rate for Payer: Local 1199SEIU Medicare	$19.43
Rate for Payer: MVP Health Care of NY Commercial	$31.67
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$23.78
Rate for Payer: MVP Health Care of NY Medicare	$17.74
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$6.33
Rate for Payer: United Healthcare Medicare	$16.89
Rate for Payer: WellCare Medicare	$23.23

Know your out-of-pocket cost for care.

All Charges