Ellenville Regional Hospital

All Charges

Charge

Type

Setting

Price

SERTRALINE HCL 100MG TABS 100 EA

Facility

$8.50

Service Code	NDC 59762491004
Hospital Charge Code	4400695
Hospital Revenue Code	250
Min. Negotiated Rate	$4.67
Max. Negotiated Rate	$5.53
Rate for Payer: Cash Price	$6.38
Rate for Payer: Galaxy Health Commercial	$5.53
Rate for Payer: WellCare Medicare	$4.67

SERTRALINE HCL 50MG TABS 10X10EA

Facility

$6.18

Service Code	NDC 59762490003
Hospital Charge Code	4400696
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

SERTRALINE HCL 50MG TABS 10X10EA

Facility

$6.18

Service Code	NDC 59762490003
Hospital Charge Code	4400696
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

SEVOFLURANE LIQD 250 ML

Facility

$6.18

Service Code	NDC 10019065364
Hospital Charge Code	4400697
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

SEVOFLURANE LIQD 250 ML

Facility

$6.18

Service Code	NDC 10019065364
Hospital Charge Code	4400697
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

SHAVE LES S/N/H/F/G; 0.5CM/<

Facility

$615.00

Service Code	HCPCS 11305
Hospital Charge Code	4856654
Hospital Revenue Code	761
Min. Negotiated Rate	$399.75
Max. Negotiated Rate	$399.75
Rate for Payer: Cash Price	$461.25
Rate for Payer: Galaxy Health Commercial	$399.75

SHAVE LES S/N/H/F/G; 0.5CM/<

Facility

$615.00

Service Code	HCPCS 11305
Hospital Charge Code	4856654
Hospital Revenue Code	761
Min. Negotiated Rate	$92.25
Max. Negotiated Rate	$492.00
Rate for Payer: Aetna of NY Commercial	$430.50
Rate for Payer: Aetna of NY Medicare	$282.90
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$246.00
Rate for Payer: Cash Price	$461.25
Rate for Payer: CDPHP Medicare	$227.55
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$492.00
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$492.00
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$492.00
Rate for Payer: EmblemHealth Medicaid	$492.00
Rate for Payer: EmblemHealth Medicare	$209.10
Rate for Payer: EmblemHealth Select Care	$442.80
Rate for Payer: Fidelis Medicare	$246.00
Rate for Payer: Galaxy Health Commercial	$399.75
Rate for Payer: Hamaspik Choice Medicare	$246.00
Rate for Payer: Humana Medicare	$246.00
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$430.50
Rate for Payer: Local 1199SEIU Medicare	$282.90
Rate for Payer: MVP Health Care of NY Commercial	$461.25
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$346.25
Rate for Payer: MVP Health Care of NY Medicare	$258.30
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$92.25
Rate for Payer: United Healthcare Medicare	$246.00
Rate for Payer: WellCare Medicare	$338.25

SHAVE LES S/N/H/F/G; 0.5CM/<

Facility

$615.00

Service Code	HCPCS 11305
Hospital Charge Code	4856695
Hospital Revenue Code	761
Min. Negotiated Rate	$399.75
Max. Negotiated Rate	$399.75
Rate for Payer: Cash Price	$461.25
Rate for Payer: Galaxy Health Commercial	$399.75

SHAVE LES S/N/H/F/G; 0.5CM/<

Facility

$615.00

Service Code	HCPCS 11305
Hospital Charge Code	4856695
Hospital Revenue Code	761
Min. Negotiated Rate	$92.25
Max. Negotiated Rate	$492.00
Rate for Payer: Aetna of NY Commercial	$430.50
Rate for Payer: Aetna of NY Medicare	$282.90
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$246.00
Rate for Payer: Cash Price	$461.25
Rate for Payer: CDPHP Medicare	$227.55
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$492.00
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$492.00
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$492.00
Rate for Payer: EmblemHealth Medicaid	$492.00
Rate for Payer: EmblemHealth Medicare	$209.10
Rate for Payer: EmblemHealth Select Care	$442.80
Rate for Payer: Fidelis Medicare	$246.00
Rate for Payer: Galaxy Health Commercial	$399.75
Rate for Payer: Hamaspik Choice Medicare	$246.00
Rate for Payer: Humana Medicare	$246.00
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$430.50
Rate for Payer: Local 1199SEIU Medicare	$282.90
Rate for Payer: MVP Health Care of NY Commercial	$461.25
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$346.25
Rate for Payer: MVP Health Care of NY Medicare	$258.30
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$92.25
Rate for Payer: United Healthcare Medicare	$246.00
Rate for Payer: WellCare Medicare	$338.25

SHAVE LES T/A/L; 0.5CM/<

Facility

$1,246.00

Service Code	HCPCS 11300
Hospital Charge Code	4856691
Hospital Revenue Code	761
Min. Negotiated Rate	$186.90
Max. Negotiated Rate	$996.80
Rate for Payer: Aetna of NY Commercial	$872.20
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: CDPHP Medicare	$461.02
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$996.80
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	$897.12
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	$872.20
Rate for Payer: Local 1199SEIU Medicare	$573.16
Rate for Payer: MVP Health Care of NY Commercial	$934.50
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$701.50
Rate for Payer: MVP Health Care of NY Medicare	$523.32
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$186.90
Rate for Payer: United Healthcare Medicare	$498.40
Rate for Payer: WellCare Medicare	$685.30

SHAVE LES T/A/L; 0.5CM/<

Facility

$1,246.00

Service Code	HCPCS 11300
Hospital Charge Code	4856691
Hospital Revenue Code	761
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

SHAVE LES T/A/L; 0.6-1.0CM

Facility

$615.00

Service Code	HCPCS 11301
Hospital Charge Code	4856692
Hospital Revenue Code	761
Min. Negotiated Rate	$92.25
Max. Negotiated Rate	$492.00
Rate for Payer: Aetna of NY Commercial	$430.50
Rate for Payer: Aetna of NY Medicare	$282.90
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$246.00
Rate for Payer: Cash Price	$461.25
Rate for Payer: CDPHP Medicare	$227.55
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$492.00
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$492.00
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$492.00
Rate for Payer: EmblemHealth Medicaid	$492.00
Rate for Payer: EmblemHealth Medicare	$209.10
Rate for Payer: EmblemHealth Select Care	$442.80
Rate for Payer: Fidelis Medicare	$246.00
Rate for Payer: Galaxy Health Commercial	$399.75
Rate for Payer: Hamaspik Choice Medicare	$246.00
Rate for Payer: Humana Medicare	$246.00
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$430.50
Rate for Payer: Local 1199SEIU Medicare	$282.90
Rate for Payer: MVP Health Care of NY Commercial	$461.25
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$346.25
Rate for Payer: MVP Health Care of NY Medicare	$258.30
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$92.25
Rate for Payer: United Healthcare Medicare	$246.00
Rate for Payer: WellCare Medicare	$338.25

SHAVE LES T/A/L; 0.6-1.0CM

Facility

$615.00

Service Code	HCPCS 11301
Hospital Charge Code	4856692
Hospital Revenue Code	761
Min. Negotiated Rate	$399.75
Max. Negotiated Rate	$399.75
Rate for Payer: Cash Price	$461.25
Rate for Payer: Galaxy Health Commercial	$399.75

SHAVE LES T/A/L; 1.1-2.0CM

Facility

$615.00

Service Code	HCPCS 11302
Hospital Charge Code	4856693
Hospital Revenue Code	761
Min. Negotiated Rate	$92.25
Max. Negotiated Rate	$492.00
Rate for Payer: Aetna of NY Commercial	$430.50
Rate for Payer: Aetna of NY Medicare	$282.90
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$246.00
Rate for Payer: Cash Price	$461.25
Rate for Payer: CDPHP Medicare	$227.55
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$492.00
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$492.00
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$492.00
Rate for Payer: EmblemHealth Medicaid	$492.00
Rate for Payer: EmblemHealth Medicare	$209.10
Rate for Payer: EmblemHealth Select Care	$442.80
Rate for Payer: Fidelis Medicare	$246.00
Rate for Payer: Galaxy Health Commercial	$399.75
Rate for Payer: Hamaspik Choice Medicare	$246.00
Rate for Payer: Humana Medicare	$246.00
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$430.50
Rate for Payer: Local 1199SEIU Medicare	$282.90
Rate for Payer: MVP Health Care of NY Commercial	$461.25
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$346.25
Rate for Payer: MVP Health Care of NY Medicare	$258.30
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$92.25
Rate for Payer: United Healthcare Medicare	$246.00
Rate for Payer: WellCare Medicare	$338.25

SHAVE LES T/A/L; 1.1-2.0CM

Facility

$615.00

Service Code	HCPCS 11302
Hospital Charge Code	4856693
Hospital Revenue Code	761
Min. Negotiated Rate	$399.75
Max. Negotiated Rate	$399.75
Rate for Payer: Cash Price	$461.25
Rate for Payer: Galaxy Health Commercial	$399.75

SHAVE LES T/A/L; > 2.0CM

Facility

$1,246.00

Service Code	HCPCS 11303
Hospital Charge Code	4856694
Hospital Revenue Code	761
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

SHAVE LES T/A/L; > 2.0CM

Facility

$1,246.00

Service Code	HCPCS 11303
Hospital Charge Code	4856694
Hospital Revenue Code	761
Min. Negotiated Rate	$186.90
Max. Negotiated Rate	$996.80
Rate for Payer: Aetna of NY Commercial	$872.20
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: CDPHP Medicare	$461.02
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$996.80
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	$897.12
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	$872.20
Rate for Payer: Local 1199SEIU Medicare	$573.16
Rate for Payer: MVP Health Care of NY Commercial	$934.50
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$701.50
Rate for Payer: MVP Health Care of NY Medicare	$523.32
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$186.90
Rate for Payer: United Healthcare Medicare	$498.40
Rate for Payer: WellCare Medicare	$685.30

SHAVE PREP TRAY 2 COMPARTMEN

Facility

$10.30

Hospital Charge Code	4471468
Hospital Revenue Code	270
Min. Negotiated Rate	$1.54
Max. Negotiated Rate	$8.24
Rate for Payer: Aetna of NY Commercial	$7.21
Rate for Payer: Aetna of NY Medicare	$4.74
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$4.12
Rate for Payer: Cash Price	$7.72
Rate for Payer: CDPHP Medicare	$3.81
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$8.24
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$8.24
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$8.24
Rate for Payer: EmblemHealth Medicaid	$8.24
Rate for Payer: EmblemHealth Medicare	$3.50
Rate for Payer: EmblemHealth Select Care	$7.42
Rate for Payer: Fidelis Medicare	$4.12
Rate for Payer: Galaxy Health Commercial	$6.70
Rate for Payer: Hamaspik Choice Medicare	$4.12
Rate for Payer: Humana Medicare	$4.12
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$7.21
Rate for Payer: Local 1199SEIU Medicare	$4.74
Rate for Payer: MVP Health Care of NY Commercial	$7.72
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$5.80
Rate for Payer: MVP Health Care of NY Medicare	$4.33
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$1.54
Rate for Payer: United Healthcare Medicare	$4.12
Rate for Payer: WellCare Medicare	$5.67

SHAVE PREP TRAY 2 COMPARTMEN

Facility

$10.30

Hospital Charge Code	4471468
Hospital Revenue Code	270
Min. Negotiated Rate	$6.70
Max. Negotiated Rate	$6.70
Rate for Payer: Cash Price	$7.72
Rate for Payer: Galaxy Health Commercial	$6.70

SHEET FLAT BARD MESH 1X4IN STE

Facility

$394.49

Hospital Charge Code	4471834
Hospital Revenue Code	270
Min. Negotiated Rate	$256.42
Max. Negotiated Rate	$256.42
Rate for Payer: Cash Price	$295.87
Rate for Payer: Galaxy Health Commercial	$256.42

SHEET FLAT BARD MESH 1X4IN STE

Facility

$394.49

Hospital Charge Code	4471834
Hospital Revenue Code	270
Min. Negotiated Rate	$59.17
Max. Negotiated Rate	$315.59
Rate for Payer: Aetna of NY Commercial	$276.14
Rate for Payer: Aetna of NY Medicare	$181.47
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$157.80
Rate for Payer: Cash Price	$295.87
Rate for Payer: CDPHP Medicare	$145.96
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$315.59
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$315.59
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$315.59
Rate for Payer: EmblemHealth Medicaid	$315.59
Rate for Payer: EmblemHealth Medicare	$134.13
Rate for Payer: EmblemHealth Select Care	$284.03
Rate for Payer: Fidelis Medicare	$157.80
Rate for Payer: Galaxy Health Commercial	$256.42
Rate for Payer: Hamaspik Choice Medicare	$157.80
Rate for Payer: Humana Medicare	$157.80
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$276.14
Rate for Payer: Local 1199SEIU Medicare	$181.47
Rate for Payer: MVP Health Care of NY Commercial	$295.87
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$222.10
Rate for Payer: MVP Health Care of NY Medicare	$165.69
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$59.17
Rate for Payer: United Healthcare Medicare	$157.80
Rate for Payer: WellCare Medicare	$216.97

SHORT ARM SPLINTS APPL STATIC

Facility

$408.00

Service Code	HCPCS 29125
Hospital Charge Code	4850021
Hospital Revenue Code	761
Min. Negotiated Rate	$265.20
Max. Negotiated Rate	$265.20
Rate for Payer: Cash Price	$306.00
Rate for Payer: Galaxy Health Commercial	$265.20

SHORT ARM SPLINTS APPL STATIC

Facility

$408.00

Service Code	HCPCS 29125
Hospital Charge Code	4850021
Hospital Revenue Code	761
Min. Negotiated Rate	$61.20
Max. Negotiated Rate	$326.40
Rate for Payer: Aetna of NY Commercial	$285.60
Rate for Payer: Aetna of NY Medicare	$187.68
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$163.20
Rate for Payer: Cash Price	$306.00
Rate for Payer: CDPHP Medicare	$150.96
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$326.40
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$326.40
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$326.40
Rate for Payer: EmblemHealth Medicaid	$326.40
Rate for Payer: EmblemHealth Medicare	$138.72
Rate for Payer: EmblemHealth Select Care	$293.76
Rate for Payer: Fidelis Medicare	$163.20
Rate for Payer: Galaxy Health Commercial	$265.20
Rate for Payer: Hamaspik Choice Medicare	$163.20
Rate for Payer: Humana Medicare	$163.20
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$285.60
Rate for Payer: Local 1199SEIU Medicare	$187.68
Rate for Payer: MVP Health Care of NY Commercial	$306.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$229.70
Rate for Payer: MVP Health Care of NY Medicare	$171.36
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$61.20
Rate for Payer: United Healthcare Medicare	$163.20
Rate for Payer: WellCare Medicare	$224.40

SHORT ARM SPLINTS OR ONLY

Facility

$408.00

Service Code	HCPCS 29125
Hospital Charge Code	4609588
Hospital Revenue Code	450
Min. Negotiated Rate	$61.20
Max. Negotiated Rate	$1,234.00
Rate for Payer: Aetna of NY Commercial	$1,000.00
Rate for Payer: Aetna of NY Medicare	$187.68
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$163.20
Rate for Payer: Cash Price	$306.00
Rate for Payer: Cash Price	$306.00
Rate for Payer: Cash Price	$306.00
Rate for Payer: CDPHP Medicare	$150.96
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$1,206.00
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$326.40
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$326.40
Rate for Payer: EmblemHealth Medicaid	$326.40
Rate for Payer: EmblemHealth Medicare	$138.72
Rate for Payer: EmblemHealth Select Care	$1,085.00
Rate for Payer: Fidelis Medicare	$163.20
Rate for Payer: Galaxy Health Commercial	$265.20
Rate for Payer: Hamaspik Choice Medicare	$163.20
Rate for Payer: Humana Medicare	$163.20
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$1,000.00
Rate for Payer: Local 1199SEIU Medicare	$187.68
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	$171.36
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$1,009.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$61.20
Rate for Payer: United Healthcare Commercial	$1,009.00
Rate for Payer: United Healthcare Medicare	$163.20
Rate for Payer: WellCare Medicare	$224.40

SHORT ARM SPLINTS OR ONLY

Facility

$408.00

Service Code	HCPCS 29125
Hospital Charge Code	4609588
Hospital Revenue Code	450
Min. Negotiated Rate	$265.20
Max. Negotiated Rate	$265.20
Rate for Payer: Cash Price	$306.00
Rate for Payer: Galaxy Health Commercial	$265.20

Know your out-of-pocket cost for care.

All Charges