Ellenville Regional Hospital

All Charges

Charge

Type

Setting

Price

RADIO-OPAQUE EPIDURAL CATHETER

Facility

$185.40

Hospital Charge Code	4479108
Hospital Revenue Code	270
Min. Negotiated Rate	$120.51
Max. Negotiated Rate	$120.51
Rate for Payer: Cash Price	$139.05
Rate for Payer: Galaxy Health Commercial	$120.51

RADIO-OPAQUE EPIDURAL CATHETER

Facility

$185.40

Hospital Charge Code	4479108
Hospital Revenue Code	270
Min. Negotiated Rate	$27.81
Max. Negotiated Rate	$148.32
Rate for Payer: Aetna of NY Commercial	$129.78
Rate for Payer: Aetna of NY Medicare	$85.28
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$74.16
Rate for Payer: Cash Price	$139.05
Rate for Payer: CDPHP Medicare	$68.60
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$148.32
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$148.32
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$148.32
Rate for Payer: EmblemHealth Medicaid	$148.32
Rate for Payer: EmblemHealth Medicare	$63.04
Rate for Payer: EmblemHealth Select Care	$133.49
Rate for Payer: Fidelis Medicare	$74.16
Rate for Payer: Galaxy Health Commercial	$120.51
Rate for Payer: Hamaspik Choice Medicare	$74.16
Rate for Payer: Humana Medicare	$74.16
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$129.78
Rate for Payer: Local 1199SEIU Medicare	$85.28
Rate for Payer: MVP Health Care of NY Commercial	$139.05
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$104.38
Rate for Payer: MVP Health Care of NY Medicare	$77.87
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$27.81
Rate for Payer: United Healthcare Medicare	$74.16
Rate for Payer: WellCare Medicare	$101.97

RADIOPHARM LOC TUMOR ; PLANAR, 1 AREA , 1 DAY

Facility

$1,225.00

Service Code	HCPCS 78800
Hospital Charge Code	4211258
Hospital Revenue Code	341
Min. Negotiated Rate	$796.25
Max. Negotiated Rate	$796.25
Rate for Payer: Cash Price	$918.75
Rate for Payer: Galaxy Health Commercial	$796.25

RADIOPHARM LOC TUMOR ; PLANAR, 1 AREA , 1 DAY

Facility

$1,225.00

Service Code	HCPCS 78800
Hospital Charge Code	4211258
Hospital Revenue Code	341
Min. Negotiated Rate	$183.75
Max. Negotiated Rate	$1,545.00
Rate for Payer: Aetna of NY Commercial	$857.50
Rate for Payer: Aetna of NY Medicare	$563.50
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$490.00
Rate for Payer: Cash Price	$918.75
Rate for Payer: Cash Price	$918.75
Rate for Payer: CDPHP Medicare	$453.25
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$857.50
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$980.00
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$980.00
Rate for Payer: EmblemHealth Medicaid	$980.00
Rate for Payer: EmblemHealth Medicare	$416.50
Rate for Payer: EmblemHealth Select Care	$796.25
Rate for Payer: Fidelis Medicare	$490.00
Rate for Payer: Galaxy Health Commercial	$796.25
Rate for Payer: Hamaspik Choice Medicare	$490.00
Rate for Payer: Humana Medicare	$490.00
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$857.50
Rate for Payer: Local 1199SEIU Medicare	$563.50
Rate for Payer: MVP Health Care of NY Commercial	$918.75
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$689.67
Rate for Payer: MVP Health Care of NY Medicare	$514.50
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$1,545.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$183.75
Rate for Payer: United Healthcare Commercial	$1,545.00
Rate for Payer: United Healthcare Medicare	$490.00
Rate for Payer: WellCare Medicare	$673.75

RADIOPHARM LOC TUMOR, PLANAR, 1 AREA, 1 DAY

Facility

$95.00

Service Code	HCPCS 78800 26
Hospital Charge Code	5211258
Hospital Revenue Code	960
Min. Negotiated Rate	$14.25
Max. Negotiated Rate	$76.00
Rate for Payer: Aetna of NY Commercial	$66.50
Rate for Payer: Aetna of NY Medicare	$43.70
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$38.00
Rate for Payer: Cash Price	$71.25
Rate for Payer: CDPHP Medicare	$35.15
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$76.00
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$76.00
Rate for Payer: EmblemHealth Medicaid	$76.00
Rate for Payer: EmblemHealth Medicare	$32.30
Rate for Payer: Fidelis Medicare	$38.00
Rate for Payer: Galaxy Health Commercial	$61.75
Rate for Payer: Hamaspik Choice Medicare	$38.00
Rate for Payer: Humana Medicare	$38.00
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$66.50
Rate for Payer: Local 1199SEIU Medicare	$43.70
Rate for Payer: MVP Health Care of NY Commercial	$71.25
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$53.48
Rate for Payer: MVP Health Care of NY Medicare	$39.90
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$14.25
Rate for Payer: United Healthcare Medicare	$38.00
Rate for Payer: WellCare Medicare	$52.25

RADIOPHARM LOC TUMOR, PLANAR, 1 AREA, 1 DAY

Facility

$95.00

Service Code	HCPCS 78800 26
Hospital Charge Code	5211258
Hospital Revenue Code	960
Min. Negotiated Rate	$61.75
Max. Negotiated Rate	$61.75
Rate for Payer: Cash Price	$71.25
Rate for Payer: Galaxy Health Commercial	$61.75

RADIOPHARM LOC TUMOR ; PLANAR, 2 OR > AREAS 2 OR > DAYS

Facility

$1,225.00

Service Code	HCPCS 78801
Hospital Charge Code	4211259
Hospital Revenue Code	341
Min. Negotiated Rate	$796.25
Max. Negotiated Rate	$796.25
Rate for Payer: Cash Price	$918.75
Rate for Payer: Galaxy Health Commercial	$796.25

RADIOPHARM LOC TUMOR ; PLANAR, 2 OR > AREAS 2 OR > DAYS

Facility

$1,225.00

Service Code	HCPCS 78801
Hospital Charge Code	4211259
Hospital Revenue Code	341
Min. Negotiated Rate	$183.75
Max. Negotiated Rate	$1,545.00
Rate for Payer: Aetna of NY Commercial	$857.50
Rate for Payer: Aetna of NY Medicare	$563.50
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$490.00
Rate for Payer: Cash Price	$918.75
Rate for Payer: Cash Price	$918.75
Rate for Payer: CDPHP Medicare	$453.25
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$857.50
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$980.00
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$980.00
Rate for Payer: EmblemHealth Medicaid	$980.00
Rate for Payer: EmblemHealth Medicare	$416.50
Rate for Payer: EmblemHealth Select Care	$796.25
Rate for Payer: Fidelis Medicare	$490.00
Rate for Payer: Galaxy Health Commercial	$796.25
Rate for Payer: Hamaspik Choice Medicare	$490.00
Rate for Payer: Humana Medicare	$490.00
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$857.50
Rate for Payer: Local 1199SEIU Medicare	$563.50
Rate for Payer: MVP Health Care of NY Commercial	$918.75
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$689.67
Rate for Payer: MVP Health Care of NY Medicare	$514.50
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$1,545.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$183.75
Rate for Payer: United Healthcare Commercial	$1,545.00
Rate for Payer: United Healthcare Medicare	$490.00
Rate for Payer: WellCare Medicare	$673.75

RADIOPHARM LOC TUMOR, PLANAR, 2 OR > AREAS 2 OR > DAYS

Facility

$104.00

Service Code	HCPCS 78801 26
Hospital Charge Code	5211259
Hospital Revenue Code	960
Min. Negotiated Rate	$67.60
Max. Negotiated Rate	$67.60
Rate for Payer: Cash Price	$78.00
Rate for Payer: Galaxy Health Commercial	$67.60

RADIOPHARM LOC TUMOR, PLANAR, 2 OR > AREAS 2 OR > DAYS

Facility

$104.00

Service Code	HCPCS 78801 26
Hospital Charge Code	5211259
Hospital Revenue Code	960
Min. Negotiated Rate	$15.60
Max. Negotiated Rate	$83.20
Rate for Payer: Aetna of NY Commercial	$72.80
Rate for Payer: Aetna of NY Medicare	$47.84
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$41.60
Rate for Payer: Cash Price	$78.00
Rate for Payer: CDPHP Medicare	$38.48
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$83.20
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$83.20
Rate for Payer: EmblemHealth Medicaid	$83.20
Rate for Payer: EmblemHealth Medicare	$35.36
Rate for Payer: Fidelis Medicare	$41.60
Rate for Payer: Galaxy Health Commercial	$67.60
Rate for Payer: Hamaspik Choice Medicare	$41.60
Rate for Payer: Humana Medicare	$41.60
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$72.80
Rate for Payer: Local 1199SEIU Medicare	$47.84
Rate for Payer: MVP Health Care of NY Commercial	$78.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$58.55
Rate for Payer: MVP Health Care of NY Medicare	$43.68
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$15.60
Rate for Payer: United Healthcare Medicare	$41.60
Rate for Payer: WellCare Medicare	$57.20

RADIOPHARM LOC TUMOR ; PLANAR, WHOLE BODY, 1 DAY

Facility

$4,063.00

Service Code	HCPCS 78802
Hospital Charge Code	4211260
Hospital Revenue Code	341
Min. Negotiated Rate	$609.45
Max. Negotiated Rate	$3,250.40
Rate for Payer: Aetna of NY Commercial	$2,844.10
Rate for Payer: Aetna of NY Medicare	$1,868.98
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$1,625.20
Rate for Payer: Cash Price	$3,047.25
Rate for Payer: Cash Price	$3,047.25
Rate for Payer: CDPHP Medicare	$1,503.31
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$2,844.10
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$3,250.40
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$3,250.40
Rate for Payer: EmblemHealth Medicaid	$3,250.40
Rate for Payer: EmblemHealth Medicare	$1,381.42
Rate for Payer: EmblemHealth Select Care	$2,640.95
Rate for Payer: Fidelis Medicare	$1,625.20
Rate for Payer: Galaxy Health Commercial	$2,640.95
Rate for Payer: Hamaspik Choice Medicare	$1,625.20
Rate for Payer: Humana Medicare	$1,625.20
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$2,844.10
Rate for Payer: Local 1199SEIU Medicare	$1,868.98
Rate for Payer: MVP Health Care of NY Commercial	$3,047.25
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$2,287.47
Rate for Payer: MVP Health Care of NY Medicare	$1,706.46
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$1,545.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$609.45
Rate for Payer: United Healthcare Commercial	$1,545.00
Rate for Payer: United Healthcare Medicare	$1,625.20
Rate for Payer: WellCare Medicare	$2,234.65

RADIOPHARM LOC TUMOR ; PLANAR, WHOLE BODY, 1 DAY

Facility

$4,063.00

Service Code	HCPCS 78802
Hospital Charge Code	4211260
Hospital Revenue Code	341
Min. Negotiated Rate	$2,640.95
Max. Negotiated Rate	$2,640.95
Rate for Payer: Cash Price	$3,047.25
Rate for Payer: Galaxy Health Commercial	$2,640.95

RADIOPHARM LOC TUMOR, PLANAR, WHOLE BODY, 1 DAY

Facility

$115.00

Service Code	HCPCS 78802 26
Hospital Charge Code	5211260
Hospital Revenue Code	960
Min. Negotiated Rate	$17.25
Max. Negotiated Rate	$92.00
Rate for Payer: Aetna of NY Commercial	$80.50
Rate for Payer: Aetna of NY Medicare	$52.90
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$46.00
Rate for Payer: Cash Price	$86.25
Rate for Payer: CDPHP Medicare	$42.55
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$92.00
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$92.00
Rate for Payer: EmblemHealth Medicaid	$92.00
Rate for Payer: EmblemHealth Medicare	$39.10
Rate for Payer: Fidelis Medicare	$46.00
Rate for Payer: Galaxy Health Commercial	$74.75
Rate for Payer: Hamaspik Choice Medicare	$46.00
Rate for Payer: Humana Medicare	$46.00
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$80.50
Rate for Payer: Local 1199SEIU Medicare	$52.90
Rate for Payer: MVP Health Care of NY Commercial	$86.25
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$64.75
Rate for Payer: MVP Health Care of NY Medicare	$48.30
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$17.25
Rate for Payer: United Healthcare Medicare	$46.00
Rate for Payer: WellCare Medicare	$63.25

RADIOPHARM LOC TUMOR, PLANAR, WHOLE BODY, 1 DAY

Facility

$115.00

Service Code	HCPCS 78802 26
Hospital Charge Code	5211260
Hospital Revenue Code	960
Min. Negotiated Rate	$74.75
Max. Negotiated Rate	$74.75
Rate for Payer: Cash Price	$86.25
Rate for Payer: Galaxy Health Commercial	$74.75

RADIOPHARM LOC TUMOR ; TOMOGRAPHIC (SPECT), 2 OR > AREAS 2 OR > DAYS

Facility

$4,063.00

Service Code	HCPCS 78831
Hospital Charge Code	4211262
Hospital Revenue Code	341
Min. Negotiated Rate	$2,640.95
Max. Negotiated Rate	$2,640.95
Rate for Payer: Cash Price	$3,047.25
Rate for Payer: Galaxy Health Commercial	$2,640.95

RADIOPHARM LOC TUMOR ; TOMOGRAPHIC (SPECT), 2 OR > AREAS 2 OR > DAYS

Facility

$4,063.00

Service Code	HCPCS 78831
Hospital Charge Code	4211262
Hospital Revenue Code	341
Min. Negotiated Rate	$609.45
Max. Negotiated Rate	$3,250.40
Rate for Payer: Aetna of NY Commercial	$1,076.00
Rate for Payer: Aetna of NY Medicare	$1,868.98
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$1,625.20
Rate for Payer: Cash Price	$3,047.25
Rate for Payer: Cash Price	$3,047.25
Rate for Payer: Cash Price	$3,047.25
Rate for Payer: CDPHP Medicare	$1,503.31
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$2,844.10
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$3,250.40
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$3,250.40
Rate for Payer: EmblemHealth Medicaid	$3,250.40
Rate for Payer: EmblemHealth Medicare	$1,381.42
Rate for Payer: EmblemHealth Select Care	$2,640.95
Rate for Payer: Fidelis Medicare	$1,625.20
Rate for Payer: Galaxy Health Commercial	$2,640.95
Rate for Payer: Hamaspik Choice Medicare	$1,625.20
Rate for Payer: Humana Medicare	$1,625.20
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$1,076.00
Rate for Payer: Local 1199SEIU Medicare	$1,868.98
Rate for Payer: MVP Health Care of NY Commercial	$3,047.25
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$2,287.47
Rate for Payer: MVP Health Care of NY Medicare	$1,706.46
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$1,545.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$609.45
Rate for Payer: United Healthcare Commercial	$1,545.00
Rate for Payer: United Healthcare Medicare	$1,625.20
Rate for Payer: WellCare Medicare	$2,234.65

RADIOPHARM LOC TUMOR, TOMOGRAPHIC (SPECT), 2 OR > AREAS 2 OR > DAYS

Facility

$258.00

Service Code	HCPCS 78831 26
Hospital Charge Code	5211262
Hospital Revenue Code	960
Min. Negotiated Rate	$38.70
Max. Negotiated Rate	$1,076.00
Rate for Payer: Aetna of NY Commercial	$1,076.00
Rate for Payer: Aetna of NY Medicare	$118.68
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$103.20
Rate for Payer: Cash Price	$193.50
Rate for Payer: Cash Price	$193.50
Rate for Payer: CDPHP Medicare	$95.46
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$206.40
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$206.40
Rate for Payer: EmblemHealth Medicaid	$206.40
Rate for Payer: EmblemHealth Medicare	$87.72
Rate for Payer: Fidelis Medicare	$103.20
Rate for Payer: Galaxy Health Commercial	$167.70
Rate for Payer: Hamaspik Choice Medicare	$103.20
Rate for Payer: Humana Medicare	$103.20
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$1,076.00
Rate for Payer: Local 1199SEIU Medicare	$118.68
Rate for Payer: MVP Health Care of NY Commercial	$193.50
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$145.25
Rate for Payer: MVP Health Care of NY Medicare	$108.36
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$38.70
Rate for Payer: United Healthcare Medicare	$103.20
Rate for Payer: WellCare Medicare	$141.90

RADIOPHARM LOC TUMOR, TOMOGRAPHIC (SPECT), 2 OR > AREAS 2 OR > DAYS

Facility

$258.00

Service Code	HCPCS 78831 26
Hospital Charge Code	5211262
Hospital Revenue Code	960
Min. Negotiated Rate	$167.70
Max. Negotiated Rate	$167.70
Rate for Payer: Cash Price	$193.50
Rate for Payer: Galaxy Health Commercial	$167.70

RADIOPHARM LOC TUMOR ; TOMOGRAPHIC (SPECT) W CT, 1 AREA, 1 DAY

Facility

$4,063.00

Service Code	HCPCS 78830
Hospital Charge Code	4211261
Hospital Revenue Code	341
Min. Negotiated Rate	$2,640.95
Max. Negotiated Rate	$2,640.95
Rate for Payer: Cash Price	$3,047.25
Rate for Payer: Galaxy Health Commercial	$2,640.95

RADIOPHARM LOC TUMOR ; TOMOGRAPHIC (SPECT) W CT, 1 AREA, 1 DAY

Facility

$4,063.00

Service Code	HCPCS 78830
Hospital Charge Code	4211261
Hospital Revenue Code	341
Min. Negotiated Rate	$609.45
Max. Negotiated Rate	$3,250.40
Rate for Payer: Aetna of NY Commercial	$1,076.00
Rate for Payer: Aetna of NY Medicare	$1,868.98
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$1,625.20
Rate for Payer: Cash Price	$3,047.25
Rate for Payer: Cash Price	$3,047.25
Rate for Payer: Cash Price	$3,047.25
Rate for Payer: CDPHP Medicare	$1,503.31
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$2,844.10
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$3,250.40
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$3,250.40
Rate for Payer: EmblemHealth Medicaid	$3,250.40
Rate for Payer: EmblemHealth Medicare	$1,381.42
Rate for Payer: EmblemHealth Select Care	$2,640.95
Rate for Payer: Fidelis Medicare	$1,625.20
Rate for Payer: Galaxy Health Commercial	$2,640.95
Rate for Payer: Hamaspik Choice Medicare	$1,625.20
Rate for Payer: Humana Medicare	$1,625.20
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$1,076.00
Rate for Payer: Local 1199SEIU Medicare	$1,868.98
Rate for Payer: MVP Health Care of NY Commercial	$3,047.25
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$2,287.47
Rate for Payer: MVP Health Care of NY Medicare	$1,706.46
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$1,545.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$609.45
Rate for Payer: United Healthcare Commercial	$1,545.00
Rate for Payer: United Healthcare Medicare	$1,625.20
Rate for Payer: WellCare Medicare	$2,234.65

RADIOPHARM LOC TUMOR, TOMOGRAPHIC (SPECT) W CT, 1 AREA, 1 DAY

Facility

$206.00

Service Code	HCPCS 78830 26
Hospital Charge Code	5211261
Hospital Revenue Code	960
Min. Negotiated Rate	$133.90
Max. Negotiated Rate	$133.90
Rate for Payer: Cash Price	$154.50
Rate for Payer: Galaxy Health Commercial	$133.90

RADIOPHARM LOC TUMOR, TOMOGRAPHIC (SPECT) W CT, 1 AREA, 1 DAY

Facility

$206.00

Service Code	HCPCS 78830 26
Hospital Charge Code	5211261
Hospital Revenue Code	960
Min. Negotiated Rate	$30.90
Max. Negotiated Rate	$1,076.00
Rate for Payer: Aetna of NY Commercial	$1,076.00
Rate for Payer: Aetna of NY Medicare	$94.76
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$82.40
Rate for Payer: Cash Price	$154.50
Rate for Payer: Cash Price	$154.50
Rate for Payer: CDPHP Medicare	$76.22
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$164.80
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$164.80
Rate for Payer: EmblemHealth Medicaid	$164.80
Rate for Payer: EmblemHealth Medicare	$70.04
Rate for Payer: Fidelis Medicare	$82.40
Rate for Payer: Galaxy Health Commercial	$133.90
Rate for Payer: Hamaspik Choice Medicare	$82.40
Rate for Payer: Humana Medicare	$82.40
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$1,076.00
Rate for Payer: Local 1199SEIU Medicare	$94.76
Rate for Payer: MVP Health Care of NY Commercial	$154.50
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$115.98
Rate for Payer: MVP Health Care of NY Medicare	$86.52
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$30.90
Rate for Payer: United Healthcare Medicare	$82.40
Rate for Payer: WellCare Medicare	$113.30

RAD. REDUCING GLOVES SIZE 7.5

Facility

$155.53

Hospital Charge Code	4471683
Hospital Revenue Code	270
Min. Negotiated Rate	$101.09
Max. Negotiated Rate	$101.09
Rate for Payer: Cash Price	$116.65
Rate for Payer: Galaxy Health Commercial	$101.09

RAD. REDUCING GLOVES SIZE 7.5

Facility

$155.53

Hospital Charge Code	4471683
Hospital Revenue Code	270
Min. Negotiated Rate	$23.33
Max. Negotiated Rate	$124.42
Rate for Payer: Aetna of NY Commercial	$108.87
Rate for Payer: Aetna of NY Medicare	$71.54
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$62.21
Rate for Payer: Cash Price	$116.65
Rate for Payer: CDPHP Medicare	$57.55
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$124.42
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$124.42
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$124.42
Rate for Payer: EmblemHealth Medicaid	$124.42
Rate for Payer: EmblemHealth Medicare	$52.88
Rate for Payer: EmblemHealth Select Care	$111.98
Rate for Payer: Fidelis Medicare	$62.21
Rate for Payer: Galaxy Health Commercial	$101.09
Rate for Payer: Hamaspik Choice Medicare	$62.21
Rate for Payer: Humana Medicare	$62.21
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$108.87
Rate for Payer: Local 1199SEIU Medicare	$71.54
Rate for Payer: MVP Health Care of NY Commercial	$116.65
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$87.56
Rate for Payer: MVP Health Care of NY Medicare	$65.32
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$23.33
Rate for Payer: United Healthcare Medicare	$62.21
Rate for Payer: WellCare Medicare	$85.54

RALOXIFENE HCL 60MG TABS 30 EA

Facility

$24.46

Service Code	NDC 60687026621
Hospital Charge Code	4400282
Hospital Revenue Code	250
Min. Negotiated Rate	$13.45
Max. Negotiated Rate	$15.90
Rate for Payer: Cash Price	$18.34
Rate for Payer: Galaxy Health Commercial	$15.90
Rate for Payer: WellCare Medicare	$13.45

Know your out-of-pocket cost for care.

All Charges