Ellenville Regional Hospital

All Charges

Charge

Type

Setting

Price

PIPERACILLIN/TAZOBACTAM INJ, 1 GRAM/0.125 GRAMS (1.125 GRAMS)

Facility

$18.46

Service Code	HCPCS J2543
Hospital Charge Code	4400826
Hospital Revenue Code	636
Min. Negotiated Rate	$1.08
Max. Negotiated Rate	$12.00
Rate for Payer: Aetna of NY Commercial	$10.15
Rate for Payer: Cash Price	$13.84
Rate for Payer: Cash Price	$13.84
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$1.08
Rate for Payer: EmblemHealth Select Care	$1.08
Rate for Payer: Galaxy Health Commercial	$12.00
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$10.15
Rate for Payer: WellCare Medicare	$10.15

PIPERACIL-TAZOBACT 2.25 GM VL 2.25 g, 1 each

Facility

$6.00

Service Code	HCPCS J2543
Hospital Charge Code	4401468
Hospital Revenue Code	636
Min. Negotiated Rate	$0.90
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	$1.08
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	$1.08
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	$2.24
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$0.90
Rate for Payer: United Healthcare Commercial	$2.24
Rate for Payer: United Healthcare Medicare	$2.40
Rate for Payer: WellCare Medicare	$3.30

PIPERACIL-TAZOBACT 2.25 GM VL 2.25 g, 1 each

Facility

$6.00

Service Code	HCPCS J2543
Hospital Charge Code	4401468
Hospital Revenue Code	636
Min. Negotiated Rate	$1.08
Max. Negotiated Rate	$3.90
Rate for Payer: Aetna of NY Commercial	$3.30
Rate for Payer: Cash Price	$4.50
Rate for Payer: Cash Price	$4.50
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$1.08
Rate for Payer: EmblemHealth Select Care	$1.08
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

PLACEMENT NEEDLE INTRAOSSEOUS INFUSION

Facility

$1,369.00

Service Code	HCPCS 36680
Hospital Charge Code	4601203
Hospital Revenue Code	450
Min. Negotiated Rate	$889.85
Max. Negotiated Rate	$889.85
Rate for Payer: Cash Price	$1,026.75
Rate for Payer: Galaxy Health Commercial	$889.85

PLACEMENT NEEDLE INTRAOSSEOUS INFUSION

Facility

$1,369.00

Service Code	HCPCS 36680
Hospital Charge Code	4601203
Hospital Revenue Code	450
Min. Negotiated Rate	$205.35
Max. Negotiated Rate	$1,234.00
Rate for Payer: Aetna of NY Commercial	$1,000.00
Rate for Payer: Aetna of NY Medicare	$629.74
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$547.60
Rate for Payer: Cash Price	$1,026.75
Rate for Payer: Cash Price	$1,026.75
Rate for Payer: Cash Price	$1,026.75
Rate for Payer: CDPHP Medicare	$506.53
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$1,206.00
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$1,095.20
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$1,095.20
Rate for Payer: EmblemHealth Medicaid	$1,095.20
Rate for Payer: EmblemHealth Medicare	$465.46
Rate for Payer: EmblemHealth Select Care	$1,085.00
Rate for Payer: Fidelis Medicare	$547.60
Rate for Payer: Galaxy Health Commercial	$889.85
Rate for Payer: Hamaspik Choice Medicare	$547.60
Rate for Payer: Humana Medicare	$547.60
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$1,000.00
Rate for Payer: Local 1199SEIU Medicare	$629.74
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	$574.98
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$1,009.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$205.35
Rate for Payer: United Healthcare Commercial	$1,009.00
Rate for Payer: United Healthcare Medicare	$547.60
Rate for Payer: WellCare Medicare	$752.95

PLAN B

Facility

$29.50

Service Code	NDC 536114263
Hospital Charge Code	4409025
Hospital Revenue Code	250
Min. Negotiated Rate	$16.23
Max. Negotiated Rate	$19.18
Rate for Payer: Cash Price	$22.12
Rate for Payer: Galaxy Health Commercial	$19.18
Rate for Payer: WellCare Medicare	$16.23

PLAN B

Facility

$29.50

Service Code	NDC 536114263
Hospital Charge Code	4409025
Hospital Revenue Code	250
Min. Negotiated Rate	$4.42
Max. Negotiated Rate	$23.60
Rate for Payer: Aetna of NY Commercial	$20.65
Rate for Payer: Aetna of NY Medicare	$13.57
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$11.80
Rate for Payer: Cash Price	$22.12
Rate for Payer: CDPHP Medicare	$10.91
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$23.60
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$23.60
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$23.60
Rate for Payer: EmblemHealth Medicaid	$23.60
Rate for Payer: EmblemHealth Medicare	$10.03
Rate for Payer: EmblemHealth Select Care	$21.24
Rate for Payer: Fidelis Medicare	$11.80
Rate for Payer: Galaxy Health Commercial	$19.18
Rate for Payer: Hamaspik Choice Medicare	$11.80
Rate for Payer: Humana Medicare	$11.80
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$20.65
Rate for Payer: Local 1199SEIU Medicare	$13.57
Rate for Payer: MVP Health Care of NY Commercial	$22.12
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$16.61
Rate for Payer: MVP Health Care of NY Medicare	$12.39
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$4.42
Rate for Payer: United Healthcare Medicare	$11.80
Rate for Payer: WellCare Medicare	$16.23

PLATELET PHERESIS LEUKOREDUCED

Facility

$1,535.00

Service Code	HCPCS P9035
Hospital Charge Code	4300634
Hospital Revenue Code	390
Min. Negotiated Rate	$767.50
Max. Negotiated Rate	$997.75
Rate for Payer: Cash Price	$1,151.25
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$767.50
Rate for Payer: EmblemHealth Select Care	$767.50
Rate for Payer: Galaxy Health Commercial	$997.75
Rate for Payer: WellCare Medicare	$844.25

PLATELET PHERESIS LEUKOREDUCED

Facility

$1,535.00

Service Code	HCPCS P9035
Hospital Charge Code	4300634
Hospital Revenue Code	390
Min. Negotiated Rate	$230.25
Max. Negotiated Rate	$1,228.00
Rate for Payer: Aetna of NY Commercial	$1,074.50
Rate for Payer: Aetna of NY Medicare	$706.10
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$614.00
Rate for Payer: Cash Price	$1,151.25
Rate for Payer: CDPHP Medicare	$567.95
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$767.50
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$1,228.00
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$1,228.00
Rate for Payer: EmblemHealth Medicaid	$1,228.00
Rate for Payer: EmblemHealth Medicare	$521.90
Rate for Payer: EmblemHealth Select Care	$767.50
Rate for Payer: Fidelis Medicare	$614.00
Rate for Payer: Galaxy Health Commercial	$997.75
Rate for Payer: Hamaspik Choice Medicare	$614.00
Rate for Payer: Humana Medicare	$614.00
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$1,074.50
Rate for Payer: Local 1199SEIU Medicare	$706.10
Rate for Payer: MVP Health Care of NY Commercial	$1,151.25
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$864.21
Rate for Payer: MVP Health Care of NY Medicare	$644.70
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$1,151.25
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$230.25
Rate for Payer: United Healthcare Commercial	$1,151.25
Rate for Payer: United Healthcare Medicare	$614.00
Rate for Payer: WellCare Medicare	$844.25

PLATELET RICH PLASMA - ONE UNIT

Facility

$1,679.00

Service Code	HCPCS P9020
Hospital Charge Code	4600270
Hospital Revenue Code	390
Min. Negotiated Rate	$251.85
Max. Negotiated Rate	$1,343.20
Rate for Payer: Aetna of NY Commercial	$1,175.30
Rate for Payer: Aetna of NY Medicare	$772.34
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$671.60
Rate for Payer: Cash Price	$1,259.25
Rate for Payer: CDPHP Medicare	$621.23
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$839.50
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$1,343.20
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$1,343.20
Rate for Payer: EmblemHealth Medicaid	$1,343.20
Rate for Payer: EmblemHealth Medicare	$570.86
Rate for Payer: EmblemHealth Select Care	$839.50
Rate for Payer: Fidelis Medicare	$671.60
Rate for Payer: Galaxy Health Commercial	$1,091.35
Rate for Payer: Hamaspik Choice Medicare	$671.60
Rate for Payer: Humana Medicare	$671.60
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$1,175.30
Rate for Payer: Local 1199SEIU Medicare	$772.34
Rate for Payer: MVP Health Care of NY Commercial	$1,259.25
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$945.28
Rate for Payer: MVP Health Care of NY Medicare	$705.18
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$1,259.25
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$251.85
Rate for Payer: United Healthcare Commercial	$1,259.25
Rate for Payer: United Healthcare Medicare	$671.60
Rate for Payer: WellCare Medicare	$923.45

PLATELET RICH PLASMA - ONE UNIT

Facility

$1,679.00

Service Code	HCPCS P9020
Hospital Charge Code	4600270
Hospital Revenue Code	390
Min. Negotiated Rate	$839.50
Max. Negotiated Rate	$1,091.35
Rate for Payer: Cash Price	$1,259.25
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$839.50
Rate for Payer: EmblemHealth Select Care	$839.50
Rate for Payer: Galaxy Health Commercial	$1,091.35
Rate for Payer: WellCare Medicare	$923.45

PLATE, PHERESIS, PATHOGEN-REDUCED, EA

Facility

$1,822.00

Service Code	HCPCS P9073
Hospital Charge Code	4302002
Hospital Revenue Code	390
Min. Negotiated Rate	$273.30
Max. Negotiated Rate	$1,457.60
Rate for Payer: Aetna of NY Commercial	$1,275.40
Rate for Payer: Aetna of NY Medicare	$838.12
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$728.80
Rate for Payer: Cash Price	$1,366.50
Rate for Payer: CDPHP Medicare	$674.14
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$911.00
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$1,457.60
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$1,457.60
Rate for Payer: EmblemHealth Medicaid	$1,457.60
Rate for Payer: EmblemHealth Medicare	$619.48
Rate for Payer: EmblemHealth Select Care	$911.00
Rate for Payer: Fidelis Medicare	$728.80
Rate for Payer: Galaxy Health Commercial	$1,184.30
Rate for Payer: Hamaspik Choice Medicare	$728.80
Rate for Payer: Humana Medicare	$728.80
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$1,275.40
Rate for Payer: Local 1199SEIU Medicare	$838.12
Rate for Payer: MVP Health Care of NY Commercial	$1,366.50
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$1,025.79
Rate for Payer: MVP Health Care of NY Medicare	$765.24
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$1,366.50
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$273.30
Rate for Payer: United Healthcare Commercial	$1,366.50
Rate for Payer: United Healthcare Medicare	$728.80
Rate for Payer: WellCare Medicare	$1,002.10

PLATE, PHERESIS, PATHOGEN-REDUCED, EA

Facility

$1,822.00

Service Code	HCPCS P9073
Hospital Charge Code	4302002
Hospital Revenue Code	390
Min. Negotiated Rate	$911.00
Max. Negotiated Rate	$1,184.30
Rate for Payer: Cash Price	$1,366.50
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$911.00
Rate for Payer: EmblemHealth Select Care	$911.00
Rate for Payer: Galaxy Health Commercial	$1,184.30
Rate for Payer: WellCare Medicare	$1,002.10

PLEUR EVAC

Facility

$139.05

Hospital Charge Code	4471133
Hospital Revenue Code	270
Min. Negotiated Rate	$90.38
Max. Negotiated Rate	$90.38
Rate for Payer: Cash Price	$104.29
Rate for Payer: Galaxy Health Commercial	$90.38

PLEUR EVAC

Facility

$139.05

Hospital Charge Code	4471133
Hospital Revenue Code	270
Min. Negotiated Rate	$20.86
Max. Negotiated Rate	$111.24
Rate for Payer: Aetna of NY Commercial	$97.33
Rate for Payer: Aetna of NY Medicare	$63.96
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$55.62
Rate for Payer: Cash Price	$104.29
Rate for Payer: CDPHP Medicare	$51.45
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$111.24
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$111.24
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$111.24
Rate for Payer: EmblemHealth Medicaid	$111.24
Rate for Payer: EmblemHealth Medicare	$47.28
Rate for Payer: EmblemHealth Select Care	$100.12
Rate for Payer: Fidelis Medicare	$55.62
Rate for Payer: Galaxy Health Commercial	$90.38
Rate for Payer: Hamaspik Choice Medicare	$55.62
Rate for Payer: Humana Medicare	$55.62
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$97.33
Rate for Payer: Local 1199SEIU Medicare	$63.96
Rate for Payer: MVP Health Care of NY Commercial	$104.29
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$78.29
Rate for Payer: MVP Health Care of NY Medicare	$58.40
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$20.86
Rate for Payer: United Healthcare Medicare	$55.62
Rate for Payer: WellCare Medicare	$76.48

PLEURX VACUUM BOTTLE 5072102

Facility

$197.76

Hospital Charge Code	4479316
Hospital Revenue Code	270
Min. Negotiated Rate	$128.54
Max. Negotiated Rate	$128.54
Rate for Payer: Cash Price	$148.32
Rate for Payer: Galaxy Health Commercial	$128.54

PLEURX VACUUM BOTTLE 5072102

Facility

$197.76

Hospital Charge Code	4479316
Hospital Revenue Code	270
Min. Negotiated Rate	$29.66
Max. Negotiated Rate	$158.21
Rate for Payer: Aetna of NY Commercial	$138.43
Rate for Payer: Aetna of NY Medicare	$90.97
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$79.10
Rate for Payer: Cash Price	$148.32
Rate for Payer: CDPHP Medicare	$73.17
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$158.21
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$158.21
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$158.21
Rate for Payer: EmblemHealth Medicaid	$158.21
Rate for Payer: EmblemHealth Medicare	$67.24
Rate for Payer: EmblemHealth Select Care	$142.39
Rate for Payer: Fidelis Medicare	$79.10
Rate for Payer: Galaxy Health Commercial	$128.54
Rate for Payer: Hamaspik Choice Medicare	$79.10
Rate for Payer: Humana Medicare	$79.10
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$138.43
Rate for Payer: Local 1199SEIU Medicare	$90.97
Rate for Payer: MVP Health Care of NY Commercial	$148.32
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$111.34
Rate for Payer: MVP Health Care of NY Medicare	$83.06
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$29.66
Rate for Payer: United Healthcare Medicare	$79.10
Rate for Payer: WellCare Medicare	$108.77

PNEUMOCOCCAL 23 VAL PSAC VACC 25MCG/0.5M

Facility

$292.52

Service Code	NDC 6494300
Hospital Charge Code	4400628
Hospital Revenue Code	250
Min. Negotiated Rate	$43.88
Max. Negotiated Rate	$234.02
Rate for Payer: Aetna of NY Commercial	$204.76
Rate for Payer: Aetna of NY Medicare	$134.56
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$117.01
Rate for Payer: Cash Price	$219.39
Rate for Payer: CDPHP Medicare	$108.23
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$234.02
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$234.02
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$234.02
Rate for Payer: EmblemHealth Medicaid	$234.02
Rate for Payer: EmblemHealth Medicare	$99.46
Rate for Payer: EmblemHealth Select Care	$210.61
Rate for Payer: Fidelis Medicare	$117.01
Rate for Payer: Galaxy Health Commercial	$190.14
Rate for Payer: Hamaspik Choice Medicare	$117.01
Rate for Payer: Humana Medicare	$117.01
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$204.76
Rate for Payer: Local 1199SEIU Medicare	$134.56
Rate for Payer: MVP Health Care of NY Commercial	$219.39
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$164.69
Rate for Payer: MVP Health Care of NY Medicare	$122.86
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$43.88
Rate for Payer: United Healthcare Medicare	$117.01
Rate for Payer: WellCare Medicare	$160.89

PNEUMOCOCCAL 23 VAL PSAC VACC 25MCG/0.5M

Facility

$292.52

Service Code	NDC 6494300
Hospital Charge Code	4400628
Hospital Revenue Code	250
Min. Negotiated Rate	$160.89
Max. Negotiated Rate	$190.14
Rate for Payer: Cash Price	$219.39
Rate for Payer: Galaxy Health Commercial	$190.14
Rate for Payer: WellCare Medicare	$160.89

PNEUMOTHORAX TRAY

Facility

$729.24

Hospital Charge Code	4479274
Hospital Revenue Code	270
Min. Negotiated Rate	$109.39
Max. Negotiated Rate	$583.39
Rate for Payer: Aetna of NY Commercial	$510.47
Rate for Payer: Aetna of NY Medicare	$335.45
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$291.70
Rate for Payer: Cash Price	$546.93
Rate for Payer: CDPHP Medicare	$269.82
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$583.39
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$583.39
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$583.39
Rate for Payer: EmblemHealth Medicaid	$583.39
Rate for Payer: EmblemHealth Medicare	$247.94
Rate for Payer: EmblemHealth Select Care	$525.05
Rate for Payer: Fidelis Medicare	$291.70
Rate for Payer: Galaxy Health Commercial	$474.01
Rate for Payer: Hamaspik Choice Medicare	$291.70
Rate for Payer: Humana Medicare	$291.70
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$510.47
Rate for Payer: Local 1199SEIU Medicare	$335.45
Rate for Payer: MVP Health Care of NY Commercial	$546.93
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$410.56
Rate for Payer: MVP Health Care of NY Medicare	$306.28
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$109.39
Rate for Payer: United Healthcare Medicare	$291.70
Rate for Payer: WellCare Medicare	$401.08

PNEUMOTHORAX TRAY

Facility

$729.24

Hospital Charge Code	4479274
Hospital Revenue Code	270
Min. Negotiated Rate	$474.01
Max. Negotiated Rate	$474.01
Rate for Payer: Cash Price	$546.93
Rate for Payer: Galaxy Health Commercial	$474.01

POLYETHYLENE GLYCOL PCKT 14 EA

Facility

$6.18

Service Code	NDC 904642286
Hospital Charge Code	4400629
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

POLYETHYLENE GLYCOL PCKT 14 EA

Facility

$6.18

Service Code	NDC 904642286
Hospital Charge Code	4400629
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

POLYMYXIN B SULF/TMP 10MU-0.1% DROP 10 M

Facility

$41.46

Service Code	NDC 24208031510
Hospital Charge Code	4400631
Hospital Revenue Code	250
Min. Negotiated Rate	$22.80
Max. Negotiated Rate	$26.95
Rate for Payer: Cash Price	$31.10
Rate for Payer: Galaxy Health Commercial	$26.95
Rate for Payer: WellCare Medicare	$22.80

POLYMYXIN B SULF/TMP 10MU-0.1% DROP 10 M

Facility

$41.46

Service Code	NDC 24208031510
Hospital Charge Code	4400631
Hospital Revenue Code	250
Min. Negotiated Rate	$6.22
Max. Negotiated Rate	$33.17
Rate for Payer: Aetna of NY Commercial	$29.02
Rate for Payer: Aetna of NY Medicare	$19.07
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$16.58
Rate for Payer: Cash Price	$31.10
Rate for Payer: CDPHP Medicare	$15.34
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$33.17
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$33.17
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$33.17
Rate for Payer: EmblemHealth Medicaid	$33.17
Rate for Payer: EmblemHealth Medicare	$14.10
Rate for Payer: EmblemHealth Select Care	$29.85
Rate for Payer: Fidelis Medicare	$16.58
Rate for Payer: Galaxy Health Commercial	$26.95
Rate for Payer: Hamaspik Choice Medicare	$16.58
Rate for Payer: Humana Medicare	$16.58
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$29.02
Rate for Payer: Local 1199SEIU Medicare	$19.07
Rate for Payer: MVP Health Care of NY Commercial	$31.09
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$23.34
Rate for Payer: MVP Health Care of NY Medicare	$17.41
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$6.22
Rate for Payer: United Healthcare Medicare	$16.58
Rate for Payer: WellCare Medicare	$22.80

Know your out-of-pocket cost for care.

All Charges