Ellenville Regional Hospital

All Charges

Charge

Type

Setting

Price

SPECTROPHOTOMETRY ANALYTE NES

Facility

$33.00

Service Code	HCPCS 84311
Hospital Charge Code	4301070
Hospital Revenue Code	301
Min. Negotiated Rate	$21.45
Max. Negotiated Rate	$21.45
Rate for Payer: Cash Price	$24.75
Rate for Payer: Galaxy Health Commercial	$21.45

SPECTROPHOTOMETRY ANALYTE NES

Facility

$33.00

Service Code	HCPCS 84311
Hospital Charge Code	4301070
Hospital Revenue Code	301
Min. Negotiated Rate	$8.10
Max. Negotiated Rate	$26.56
Rate for Payer: Aetna of NY Commercial	$21.45
Rate for Payer: Aetna of NY Medicare	$15.18
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group	$24.75
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO	$24.75
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$12.21
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp	$16.50
Rate for Payer: Cash Price	$24.75
Rate for Payer: Cash Price	$24.75
Rate for Payer: CDPHP Commercial	$26.56
Rate for Payer: CDPHP Medicare	$12.21
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$19.80
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$26.40
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$26.40
Rate for Payer: EmblemHealth Medicaid	$26.40
Rate for Payer: EmblemHealth Medicare	$11.22
Rate for Payer: EmblemHealth Select Care	$19.80
Rate for Payer: Fidelis Medicare	$12.58
Rate for Payer: Galaxy Health Commercial	$21.45
Rate for Payer: Hamaspik Choice Medicare	$12.21
Rate for Payer: Humana Medicare	$12.21
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$21.45
Rate for Payer: Local 1199SEIU Medicare	$15.18
Rate for Payer: MVP Health Care of NY Commercial	$24.75
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$18.58
Rate for Payer: MVP Health Care of NY Medicare	$12.82
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$24.75
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$8.10
Rate for Payer: United Healthcare Commercial	$24.75
Rate for Payer: United Healthcare Medicare	$12.21
Rate for Payer: WellCare Medicare	$18.15

SPINAL NEEDLE 22G X 5.0

Facility

$28.00

Hospital Charge Code	4473035
Hospital Revenue Code	272
Min. Negotiated Rate	$9.52
Max. Negotiated Rate	$22.54
Rate for Payer: Aetna of NY Commercial	$19.60
Rate for Payer: Aetna of NY Medicare	$12.88
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group	$21.00
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO	$21.00
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$10.36
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp	$14.00
Rate for Payer: Cash Price	$21.00
Rate for Payer: CDPHP Commercial	$22.54
Rate for Payer: CDPHP Medicare	$10.36
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$22.40
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$22.40
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$22.40
Rate for Payer: EmblemHealth Medicaid	$22.40
Rate for Payer: EmblemHealth Medicare	$9.52
Rate for Payer: EmblemHealth Select Care	$20.16
Rate for Payer: Fidelis Medicare	$10.67
Rate for Payer: Galaxy Health Commercial	$18.20
Rate for Payer: Hamaspik Choice Medicare	$10.36
Rate for Payer: Humana Medicare	$10.36
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$19.60
Rate for Payer: Local 1199SEIU Medicare	$12.88
Rate for Payer: MVP Health Care of NY Commercial	$21.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$15.76
Rate for Payer: MVP Health Care of NY Medicare	$10.88
Rate for Payer: United Healthcare Medicare	$10.36
Rate for Payer: WellCare Medicare	$15.40

SPINAL NEEDLE 22G X 5.0

Facility

$28.00

Hospital Charge Code	4473035
Hospital Revenue Code	272
Min. Negotiated Rate	$18.20
Max. Negotiated Rate	$18.20
Rate for Payer: Cash Price	$21.00
Rate for Payer: Galaxy Health Commercial	$18.20

SPINAL PUNCTURE LUMBAR DIAGNOSTIC

Facility

$1,979.00

Service Code	HCPCS 62270
Hospital Charge Code	4600155
Hospital Revenue Code	450
Min. Negotiated Rate	$250.00
Max. Negotiated Rate	$1,593.10
Rate for Payer: Aetna of NY Commercial	$955.00
Rate for Payer: Aetna of NY Medicare	$910.34
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group	$950.93
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO	$1,189.18
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$732.23
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp	$989.50
Rate for Payer: Cash Price	$1,484.25
Rate for Payer: Cash Price	$1,484.25
Rate for Payer: Cash Price	$1,484.25
Rate for Payer: Cash Price	$1,484.25
Rate for Payer: CDPHP Commercial	$1,593.10
Rate for Payer: CDPHP Medicare	$732.23
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$1,182.00
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$1,583.20
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$1,583.20
Rate for Payer: EmblemHealth Medicaid	$1,583.20
Rate for Payer: EmblemHealth Medicare	$672.86
Rate for Payer: EmblemHealth Select Care	$1,064.00
Rate for Payer: Fidelis Child Health Plus/Essential Plan/HARP/Medicaid	$250.00
Rate for Payer: Fidelis Medicare	$754.20
Rate for Payer: Galaxy Health Commercial	$1,286.35
Rate for Payer: Hamaspik Choice Medicare	$732.23
Rate for Payer: Humana Medicare	$732.23
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$955.00
Rate for Payer: Local 1199SEIU Medicare	$910.34
Rate for Payer: MVP Health Care of NY Commercial	$1,174.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$881.00
Rate for Payer: MVP Health Care of NY Medicare	$768.84
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$980.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$658.90
Rate for Payer: United Healthcare Commercial	$980.00
Rate for Payer: United Healthcare Medicare	$732.23
Rate for Payer: WellCare Medicare	$1,088.45

SPINAL PUNCTURE LUMBAR DIAGNOSTIC

Facility

$1,979.00

Service Code	HCPCS 62270
Hospital Charge Code	4600155
Hospital Revenue Code	450
Min. Negotiated Rate	$1,286.35
Max. Negotiated Rate	$1,286.35
Rate for Payer: Cash Price	$1,484.25
Rate for Payer: Galaxy Health Commercial	$1,286.35

SPINAL TRAY 25GA WHITACRE

Facility

$57.00

Hospital Charge Code	4471393
Hospital Revenue Code	270
Min. Negotiated Rate	$19.38
Max. Negotiated Rate	$45.88
Rate for Payer: Aetna of NY Commercial	$39.90
Rate for Payer: Aetna of NY Medicare	$26.22
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group	$42.75
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO	$42.75
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$21.09
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp	$28.50
Rate for Payer: Cash Price	$42.75
Rate for Payer: CDPHP Commercial	$45.88
Rate for Payer: CDPHP Medicare	$21.09
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$45.60
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$45.60
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$45.60
Rate for Payer: EmblemHealth Medicaid	$45.60
Rate for Payer: EmblemHealth Medicare	$19.38
Rate for Payer: EmblemHealth Select Care	$41.04
Rate for Payer: Fidelis Medicare	$21.72
Rate for Payer: Galaxy Health Commercial	$37.05
Rate for Payer: Hamaspik Choice Medicare	$21.09
Rate for Payer: Humana Medicare	$21.09
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$39.90
Rate for Payer: Local 1199SEIU Medicare	$26.22
Rate for Payer: MVP Health Care of NY Commercial	$42.75
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$32.09
Rate for Payer: MVP Health Care of NY Medicare	$22.14
Rate for Payer: United Healthcare Medicare	$21.09
Rate for Payer: WellCare Medicare	$31.35

SPINAL TRAY 25GA WHITACRE

Facility

$57.00

Hospital Charge Code	4471393
Hospital Revenue Code	270
Min. Negotiated Rate	$37.05
Max. Negotiated Rate	$37.05
Rate for Payer: Cash Price	$42.75
Rate for Payer: Galaxy Health Commercial	$37.05

Spiriva RESPIMAT 2.5 MCG INH 2.5 mcg, 4 g

Facility

$270.00

Service Code	NDC 00597010051
Hospital Charge Code	4401402
Hospital Revenue Code	250
Min. Negotiated Rate	$148.50
Max. Negotiated Rate	$175.50
Rate for Payer: Cash Price	$202.50
Rate for Payer: Galaxy Health Commercial	$175.50
Rate for Payer: WellCare Medicare	$148.50

Spiriva RESPIMAT 2.5 MCG INH 2.5 mcg, 4 g

Facility

$270.00

Service Code	NDC 00597010051
Hospital Charge Code	4401402
Hospital Revenue Code	250
Min. Negotiated Rate	$91.80
Max. Negotiated Rate	$217.35
Rate for Payer: Aetna of NY Commercial	$189.00
Rate for Payer: Aetna of NY Medicare	$124.20
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group	$202.50
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO	$202.50
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$99.90
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp	$135.00
Rate for Payer: Cash Price	$202.50
Rate for Payer: CDPHP Commercial	$217.35
Rate for Payer: CDPHP Medicare	$99.90
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$216.00
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$216.00
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$216.00
Rate for Payer: EmblemHealth Medicaid	$216.00
Rate for Payer: EmblemHealth Medicare	$91.80
Rate for Payer: EmblemHealth Select Care	$194.40
Rate for Payer: Fidelis Medicare	$102.90
Rate for Payer: Galaxy Health Commercial	$175.50
Rate for Payer: Hamaspik Choice Medicare	$99.90
Rate for Payer: Humana Medicare	$99.90
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$189.00
Rate for Payer: Local 1199SEIU Medicare	$124.20
Rate for Payer: MVP Health Care of NY Commercial	$202.50
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$152.01
Rate for Payer: MVP Health Care of NY Medicare	$104.90
Rate for Payer: United Healthcare Medicare	$99.90
Rate for Payer: WellCare Medicare	$148.50

SPIROMETER COACH-2

Facility

$34.00

Hospital Charge Code	4472096
Hospital Revenue Code	270
Min. Negotiated Rate	$22.10
Max. Negotiated Rate	$22.10
Rate for Payer: Cash Price	$25.50
Rate for Payer: Galaxy Health Commercial	$22.10

SPIROMETER COACH-2

Facility

$34.00

Hospital Charge Code	4472096
Hospital Revenue Code	270
Min. Negotiated Rate	$11.56
Max. Negotiated Rate	$27.37
Rate for Payer: Aetna of NY Commercial	$23.80
Rate for Payer: Aetna of NY Medicare	$15.64
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group	$25.50
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO	$25.50
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$12.58
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp	$17.00
Rate for Payer: Cash Price	$25.50
Rate for Payer: CDPHP Commercial	$27.37
Rate for Payer: CDPHP Medicare	$12.58
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$27.20
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$27.20
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$27.20
Rate for Payer: EmblemHealth Medicaid	$27.20
Rate for Payer: EmblemHealth Medicare	$11.56
Rate for Payer: EmblemHealth Select Care	$24.48
Rate for Payer: Fidelis Medicare	$12.96
Rate for Payer: Galaxy Health Commercial	$22.10
Rate for Payer: Hamaspik Choice Medicare	$12.58
Rate for Payer: Humana Medicare	$12.58
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$23.80
Rate for Payer: Local 1199SEIU Medicare	$15.64
Rate for Payer: MVP Health Care of NY Commercial	$25.50
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$19.14
Rate for Payer: MVP Health Care of NY Medicare	$13.21
Rate for Payer: United Healthcare Medicare	$12.58
Rate for Payer: WellCare Medicare	$18.70

SPIROMETRY

Facility

$447.00

Service Code	HCPCS 94010
Hospital Charge Code	4530044
Hospital Revenue Code	460
Min. Negotiated Rate	$290.55
Max. Negotiated Rate	$290.55
Rate for Payer: Cash Price	$335.25
Rate for Payer: Galaxy Health Commercial	$290.55

SPIROMETRY

Facility

$447.00

Service Code	HCPCS 94010
Hospital Charge Code	4530044
Hospital Revenue Code	460
Min. Negotiated Rate	$15.15
Max. Negotiated Rate	$359.84
Rate for Payer: Aetna of NY Commercial	$312.90
Rate for Payer: Aetna of NY Medicare	$205.62
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group	$335.25
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO	$335.25
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$165.39
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp	$223.50
Rate for Payer: Cash Price	$335.25
Rate for Payer: Cash Price	$335.25
Rate for Payer: CDPHP Commercial	$359.84
Rate for Payer: CDPHP Medicare	$165.39
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$312.90
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$357.60
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$357.60
Rate for Payer: EmblemHealth Medicaid	$357.60
Rate for Payer: EmblemHealth Medicare	$151.98
Rate for Payer: EmblemHealth Select Care	$290.55
Rate for Payer: Fidelis Medicare	$170.35
Rate for Payer: Galaxy Health Commercial	$290.55
Rate for Payer: Hamaspik Choice Medicare	$165.39
Rate for Payer: Humana Medicare	$165.39
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$312.90
Rate for Payer: Local 1199SEIU Medicare	$205.62
Rate for Payer: MVP Health Care of NY Commercial	$335.25
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$251.66
Rate for Payer: MVP Health Care of NY Medicare	$173.66
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$15.15
Rate for Payer: United Healthcare Medicare	$165.39
Rate for Payer: WellCare Medicare	$245.85

SPIROMTR,VOL INCENT4000ML W

Facility

$10.00

Hospital Charge Code	4471017
Hospital Revenue Code	270
Min. Negotiated Rate	$6.50
Max. Negotiated Rate	$6.50
Rate for Payer: Cash Price	$7.50
Rate for Payer: Galaxy Health Commercial	$6.50

SPIROMTR,VOL INCENT4000ML W

Facility

$10.00

Hospital Charge Code	4471017
Hospital Revenue Code	270
Min. Negotiated Rate	$3.40
Max. Negotiated Rate	$8.05
Rate for Payer: Aetna of NY Commercial	$7.00
Rate for Payer: Aetna of NY Medicare	$4.60
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group	$7.50
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO	$7.50
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$3.70
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp	$5.00
Rate for Payer: Cash Price	$7.50
Rate for Payer: CDPHP Commercial	$8.05
Rate for Payer: CDPHP Medicare	$3.70
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$8.00
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$8.00
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$8.00
Rate for Payer: EmblemHealth Medicaid	$8.00
Rate for Payer: EmblemHealth Medicare	$3.40
Rate for Payer: EmblemHealth Select Care	$7.20
Rate for Payer: Fidelis Medicare	$3.81
Rate for Payer: Galaxy Health Commercial	$6.50
Rate for Payer: Hamaspik Choice Medicare	$3.70
Rate for Payer: Humana Medicare	$3.70
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$7.00
Rate for Payer: Local 1199SEIU Medicare	$4.60
Rate for Payer: MVP Health Care of NY Commercial	$7.50
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$5.63
Rate for Payer: MVP Health Care of NY Medicare	$3.88
Rate for Payer: United Healthcare Medicare	$3.70
Rate for Payer: WellCare Medicare	$5.50

SPIRONOLACTONE 25MG TABS 10X10EA

Facility

$6.18

Service Code	NDC 51079010320
Hospital Charge Code	4400717
Hospital Revenue Code	250
Min. Negotiated Rate	$2.10
Max. Negotiated Rate	$4.97
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) Blue Access/Small Group	$4.64
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO	$4.64
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$2.29
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp	$3.09
Rate for Payer: Cash Price	$4.64
Rate for Payer: CDPHP Commercial	$4.97
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	$2.36
Rate for Payer: Galaxy Health Commercial	$4.02
Rate for Payer: Hamaspik Choice Medicare	$2.29
Rate for Payer: Humana Medicare	$2.29
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	$4.64
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$3.48
Rate for Payer: MVP Health Care of NY Medicare	$2.40
Rate for Payer: United Healthcare Medicare	$2.29
Rate for Payer: WellCare Medicare	$3.40

SPIRONOLACTONE 25MG TABS 10X10EA

Facility

$6.18

Service Code	NDC 51079010320
Hospital Charge Code	4400717
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

SPL AVULSE NP; EA ADDTL

Facility

$63.00

Service Code	HCPCS 11732
Hospital Charge Code	4856672
Hospital Revenue Code	761
Min. Negotiated Rate	$16.64
Max. Negotiated Rate	$2,521.93
Rate for Payer: Aetna of NY Commercial	$44.10
Rate for Payer: Aetna of NY Medicare	$28.98
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group	$2,017.33
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO	$2,521.93
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$23.31
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp	$31.50
Rate for Payer: Cash Price	$47.25
Rate for Payer: Cash Price	$47.25
Rate for Payer: Cash Price	$47.25
Rate for Payer: CDPHP Commercial	$50.72
Rate for Payer: CDPHP Medicare	$23.31
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$50.40
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$50.40
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$50.40
Rate for Payer: EmblemHealth Medicaid	$50.40
Rate for Payer: EmblemHealth Medicare	$21.42
Rate for Payer: EmblemHealth Select Care	$45.36
Rate for Payer: Fidelis Medicare	$24.01
Rate for Payer: Galaxy Health Commercial	$40.95
Rate for Payer: Hamaspik Choice Medicare	$23.31
Rate for Payer: Humana Medicare	$23.31
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$44.10
Rate for Payer: Local 1199SEIU Medicare	$28.98
Rate for Payer: MVP Health Care of NY Commercial	$47.25
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$35.47
Rate for Payer: MVP Health Care of NY Medicare	$24.48
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$16.64
Rate for Payer: United Healthcare Medicare	$23.31
Rate for Payer: WellCare Medicare	$34.65

SPL AVULSE NP; EA ADDTL

Facility

$63.00

Service Code	HCPCS 11732
Hospital Charge Code	4856672
Hospital Revenue Code	761
Min. Negotiated Rate	$40.95
Max. Negotiated Rate	$40.95
Rate for Payer: Cash Price	$47.25
Rate for Payer: Galaxy Health Commercial	$40.95

SPONGE GAUZE CURITY 4X4IN 12-P

Facility

$2.00

Hospital Charge Code	4471631
Hospital Revenue Code	270
Min. Negotiated Rate	$1.30
Max. Negotiated Rate	$1.30
Rate for Payer: Cash Price	$1.50
Rate for Payer: Galaxy Health Commercial	$1.30

SPONGE GAUZE CURITY 4X4IN 12-P

Facility

$2.00

Hospital Charge Code	4471631
Hospital Revenue Code	270
Min. Negotiated Rate	$0.68
Max. Negotiated Rate	$1.61
Rate for Payer: Aetna of NY Commercial	$1.40
Rate for Payer: Aetna of NY Medicare	$0.92
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group	$1.50
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO	$1.50
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$0.74
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp	$1.00
Rate for Payer: Cash Price	$1.50
Rate for Payer: CDPHP Commercial	$1.61
Rate for Payer: CDPHP Medicare	$0.74
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$1.60
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$1.60
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$1.60
Rate for Payer: EmblemHealth Medicaid	$1.60
Rate for Payer: EmblemHealth Medicare	$0.68
Rate for Payer: EmblemHealth Select Care	$1.44
Rate for Payer: Fidelis Medicare	$0.76
Rate for Payer: Galaxy Health Commercial	$1.30
Rate for Payer: Hamaspik Choice Medicare	$0.74
Rate for Payer: Humana Medicare	$0.74
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$1.40
Rate for Payer: Local 1199SEIU Medicare	$0.92
Rate for Payer: MVP Health Care of NY Commercial	$1.50
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$1.13
Rate for Payer: MVP Health Care of NY Medicare	$0.78
Rate for Payer: United Healthcare Medicare	$0.74
Rate for Payer: WellCare Medicare	$1.10

SPOT INDIAN INK

Facility

$75.00

Hospital Charge Code	4479078
Hospital Revenue Code	270
Min. Negotiated Rate	$48.75
Max. Negotiated Rate	$48.75
Rate for Payer: Cash Price	$56.25
Rate for Payer: Galaxy Health Commercial	$48.75

SPOT INDIAN INK

Facility

$75.00

Hospital Charge Code	4479078
Hospital Revenue Code	270
Min. Negotiated Rate	$25.50
Max. Negotiated Rate	$60.38
Rate for Payer: Aetna of NY Commercial	$52.50
Rate for Payer: Aetna of NY Medicare	$34.50
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group	$56.25
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO	$56.25
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$27.75
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp	$37.50
Rate for Payer: Cash Price	$56.25
Rate for Payer: CDPHP Commercial	$60.38
Rate for Payer: CDPHP Medicare	$27.75
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$60.00
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$60.00
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$60.00
Rate for Payer: EmblemHealth Medicaid	$60.00
Rate for Payer: EmblemHealth Medicare	$25.50
Rate for Payer: EmblemHealth Select Care	$54.00
Rate for Payer: Fidelis Medicare	$28.58
Rate for Payer: Galaxy Health Commercial	$48.75
Rate for Payer: Hamaspik Choice Medicare	$27.75
Rate for Payer: Humana Medicare	$27.75
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$52.50
Rate for Payer: Local 1199SEIU Medicare	$34.50
Rate for Payer: MVP Health Care of NY Commercial	$56.25
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$42.22
Rate for Payer: MVP Health Care of NY Medicare	$29.14
Rate for Payer: United Healthcare Medicare	$27.75
Rate for Payer: WellCare Medicare	$41.25

SREP S/N/A/G/TR/E; 2.5CM/<

Facility

$573.00

Service Code	HCPCS 12001
Hospital Charge Code	4852000
Hospital Revenue Code	761
Min. Negotiated Rate	$372.45
Max. Negotiated Rate	$372.45
Rate for Payer: Cash Price	$429.75
Rate for Payer: Galaxy Health Commercial	$372.45

Know your out-of-pocket cost for care.

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