Ellenville Regional Hospital

All Charges

Charge

Type

Setting

Price

SHORT LEG CAST APPLICATION

Facility

$857.00

Service Code	HCPCS 29405
Hospital Charge Code	4850016
Hospital Revenue Code	761
Min. Negotiated Rate	$557.05
Max. Negotiated Rate	$557.05
Rate for Payer: Cash Price	$642.75
Rate for Payer: Galaxy Health Commercial	$557.05

SHORT LEG CAST APPLICATION

Facility

$857.00

Service Code	HCPCS 29405
Hospital Charge Code	4850016
Hospital Revenue Code	761
Min. Negotiated Rate	$128.55
Max. Negotiated Rate	$685.60
Rate for Payer: Aetna of NY Commercial	$599.90
Rate for Payer: Aetna of NY Medicare	$394.22
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$342.80
Rate for Payer: Cash Price	$642.75
Rate for Payer: CDPHP Medicare	$317.09
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$685.60
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$685.60
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$685.60
Rate for Payer: EmblemHealth Medicaid	$685.60
Rate for Payer: EmblemHealth Medicare	$291.38
Rate for Payer: EmblemHealth Select Care	$617.04
Rate for Payer: Fidelis Medicare	$342.80
Rate for Payer: Galaxy Health Commercial	$557.05
Rate for Payer: Hamaspik Choice Medicare	$342.80
Rate for Payer: Humana Medicare	$342.80
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$599.90
Rate for Payer: Local 1199SEIU Medicare	$394.22
Rate for Payer: MVP Health Care of NY Commercial	$642.75
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$482.49
Rate for Payer: MVP Health Care of NY Medicare	$359.94
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$128.55
Rate for Payer: United Healthcare Medicare	$342.80
Rate for Payer: WellCare Medicare	$471.35

SHORT LEG SPLINT

Facility

$498.00

Service Code	HCPCS 29515
Hospital Charge Code	4850024
Hospital Revenue Code	761
Min. Negotiated Rate	$74.70
Max. Negotiated Rate	$398.40
Rate for Payer: Aetna of NY Commercial	$348.60
Rate for Payer: Aetna of NY Medicare	$229.08
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$199.20
Rate for Payer: Cash Price	$373.50
Rate for Payer: CDPHP Medicare	$184.26
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$398.40
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$398.40
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$398.40
Rate for Payer: EmblemHealth Medicaid	$398.40
Rate for Payer: EmblemHealth Medicare	$169.32
Rate for Payer: EmblemHealth Select Care	$358.56
Rate for Payer: Fidelis Medicare	$199.20
Rate for Payer: Galaxy Health Commercial	$323.70
Rate for Payer: Hamaspik Choice Medicare	$199.20
Rate for Payer: Humana Medicare	$199.20
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$348.60
Rate for Payer: Local 1199SEIU Medicare	$229.08
Rate for Payer: MVP Health Care of NY Commercial	$373.50
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$280.37
Rate for Payer: MVP Health Care of NY Medicare	$209.16
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$74.70
Rate for Payer: United Healthcare Medicare	$199.20
Rate for Payer: WellCare Medicare	$273.90

SHORT LEG SPLINT

Facility

$498.00

Service Code	HCPCS 29515
Hospital Charge Code	4850024
Hospital Revenue Code	761
Min. Negotiated Rate	$323.70
Max. Negotiated Rate	$323.70
Rate for Payer: Cash Price	$373.50
Rate for Payer: Galaxy Health Commercial	$323.70

SHORT LEG WALKING CAST APPLICATION

Facility

$857.00

Service Code	HCPCS 29425
Hospital Charge Code	4850017
Hospital Revenue Code	761
Min. Negotiated Rate	$128.55
Max. Negotiated Rate	$685.60
Rate for Payer: Aetna of NY Commercial	$599.90
Rate for Payer: Aetna of NY Medicare	$394.22
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$342.80
Rate for Payer: Cash Price	$642.75
Rate for Payer: CDPHP Medicare	$317.09
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$685.60
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$685.60
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$685.60
Rate for Payer: EmblemHealth Medicaid	$685.60
Rate for Payer: EmblemHealth Medicare	$291.38
Rate for Payer: EmblemHealth Select Care	$617.04
Rate for Payer: Fidelis Medicare	$342.80
Rate for Payer: Galaxy Health Commercial	$557.05
Rate for Payer: Hamaspik Choice Medicare	$342.80
Rate for Payer: Humana Medicare	$342.80
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$599.90
Rate for Payer: Local 1199SEIU Medicare	$394.22
Rate for Payer: MVP Health Care of NY Commercial	$642.75
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$482.49
Rate for Payer: MVP Health Care of NY Medicare	$359.94
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$128.55
Rate for Payer: United Healthcare Medicare	$342.80
Rate for Payer: WellCare Medicare	$471.35

SHORT LEG WALKING CAST APPLICATION

Facility

$857.00

Service Code	HCPCS 29425
Hospital Charge Code	4850017
Hospital Revenue Code	761
Min. Negotiated Rate	$557.05
Max. Negotiated Rate	$557.05
Rate for Payer: Cash Price	$642.75
Rate for Payer: Galaxy Health Commercial	$557.05

SHORT THROW SNARE STAND

Facility

$20.60

Hospital Charge Code	4479099
Hospital Revenue Code	270
Min. Negotiated Rate	$13.39
Max. Negotiated Rate	$13.39
Rate for Payer: Cash Price	$15.45
Rate for Payer: Galaxy Health Commercial	$13.39

SHORT THROW SNARE STAND

Facility

$20.60

Hospital Charge Code	4479099
Hospital Revenue Code	270
Min. Negotiated Rate	$3.09
Max. Negotiated Rate	$16.48
Rate for Payer: Aetna of NY Commercial	$14.42
Rate for Payer: Aetna of NY Medicare	$9.48
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$8.24
Rate for Payer: Cash Price	$15.45
Rate for Payer: CDPHP Medicare	$7.62
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$16.48
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$16.48
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$16.48
Rate for Payer: EmblemHealth Medicaid	$16.48
Rate for Payer: EmblemHealth Medicare	$7.00
Rate for Payer: EmblemHealth Select Care	$14.83
Rate for Payer: Fidelis Medicare	$8.24
Rate for Payer: Galaxy Health Commercial	$13.39
Rate for Payer: Hamaspik Choice Medicare	$8.24
Rate for Payer: Humana Medicare	$8.24
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$14.42
Rate for Payer: Local 1199SEIU Medicare	$9.48
Rate for Payer: MVP Health Care of NY Commercial	$15.45
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$11.60
Rate for Payer: MVP Health Care of NY Medicare	$8.65
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$3.09
Rate for Payer: United Healthcare Medicare	$8.24
Rate for Payer: WellCare Medicare	$11.33

SHOULDER ARTHROSCOPY PACK#7779972

Facility

$368.74

Hospital Charge Code	4479277
Hospital Revenue Code	270
Min. Negotiated Rate	$239.68
Max. Negotiated Rate	$239.68
Rate for Payer: Cash Price	$276.56
Rate for Payer: Galaxy Health Commercial	$239.68

SHOULDER ARTHROSCOPY PACK#7779972

Facility

$368.74

Hospital Charge Code	4479277
Hospital Revenue Code	270
Min. Negotiated Rate	$55.31
Max. Negotiated Rate	$294.99
Rate for Payer: Aetna of NY Commercial	$258.12
Rate for Payer: Aetna of NY Medicare	$169.62
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$147.50
Rate for Payer: Cash Price	$276.56
Rate for Payer: CDPHP Medicare	$136.43
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$294.99
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$294.99
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$294.99
Rate for Payer: EmblemHealth Medicaid	$294.99
Rate for Payer: EmblemHealth Medicare	$125.37
Rate for Payer: EmblemHealth Select Care	$265.49
Rate for Payer: Fidelis Medicare	$147.50
Rate for Payer: Galaxy Health Commercial	$239.68
Rate for Payer: Hamaspik Choice Medicare	$147.50
Rate for Payer: Humana Medicare	$147.50
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$258.12
Rate for Payer: Local 1199SEIU Medicare	$169.62
Rate for Payer: MVP Health Care of NY Commercial	$276.56
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$207.60
Rate for Payer: MVP Health Care of NY Medicare	$154.87
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$55.31
Rate for Payer: United Healthcare Medicare	$147.50
Rate for Payer: WellCare Medicare	$202.81

SHOULDER IMMOB W/FOAM L

Facility

$33.99

Hospital Charge Code	4471281
Hospital Revenue Code	270
Min. Negotiated Rate	$22.09
Max. Negotiated Rate	$22.09
Rate for Payer: Cash Price	$25.49
Rate for Payer: Galaxy Health Commercial	$22.09

SHOULDER IMMOB W/FOAM L

Facility

$33.99

Hospital Charge Code	4471281
Hospital Revenue Code	270
Min. Negotiated Rate	$5.10
Max. Negotiated Rate	$27.19
Rate for Payer: Aetna of NY Commercial	$23.79
Rate for Payer: Aetna of NY Medicare	$15.64
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$13.60
Rate for Payer: Cash Price	$25.49
Rate for Payer: CDPHP Medicare	$12.58
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$27.19
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$27.19
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$27.19
Rate for Payer: EmblemHealth Medicaid	$27.19
Rate for Payer: EmblemHealth Medicare	$11.56
Rate for Payer: EmblemHealth Select Care	$24.47
Rate for Payer: Fidelis Medicare	$13.60
Rate for Payer: Galaxy Health Commercial	$22.09
Rate for Payer: Hamaspik Choice Medicare	$13.60
Rate for Payer: Humana Medicare	$13.60
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$23.79
Rate for Payer: Local 1199SEIU Medicare	$15.64
Rate for Payer: MVP Health Care of NY Commercial	$25.49
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$19.14
Rate for Payer: MVP Health Care of NY Medicare	$14.28
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$5.10
Rate for Payer: United Healthcare Medicare	$13.60
Rate for Payer: WellCare Medicare	$18.69

SHOULDER IMMOB W/FOAM M

Facility

$33.99

Hospital Charge Code	4471188
Hospital Revenue Code	270
Min. Negotiated Rate	$22.09
Max. Negotiated Rate	$22.09
Rate for Payer: Cash Price	$25.49
Rate for Payer: Galaxy Health Commercial	$22.09

SHOULDER IMMOB W/FOAM M

Facility

$33.99

Hospital Charge Code	4471188
Hospital Revenue Code	270
Min. Negotiated Rate	$5.10
Max. Negotiated Rate	$27.19
Rate for Payer: Aetna of NY Commercial	$23.79
Rate for Payer: Aetna of NY Medicare	$15.64
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$13.60
Rate for Payer: Cash Price	$25.49
Rate for Payer: CDPHP Medicare	$12.58
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$27.19
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$27.19
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$27.19
Rate for Payer: EmblemHealth Medicaid	$27.19
Rate for Payer: EmblemHealth Medicare	$11.56
Rate for Payer: EmblemHealth Select Care	$24.47
Rate for Payer: Fidelis Medicare	$13.60
Rate for Payer: Galaxy Health Commercial	$22.09
Rate for Payer: Hamaspik Choice Medicare	$13.60
Rate for Payer: Humana Medicare	$13.60
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$23.79
Rate for Payer: Local 1199SEIU Medicare	$15.64
Rate for Payer: MVP Health Care of NY Commercial	$25.49
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$19.14
Rate for Payer: MVP Health Care of NY Medicare	$14.28
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$5.10
Rate for Payer: United Healthcare Medicare	$13.60
Rate for Payer: WellCare Medicare	$18.69

SHOULDER IMMOB W/FOAM ST XL

Facility

$35.02

Hospital Charge Code	4471344
Hospital Revenue Code	270
Min. Negotiated Rate	$5.25
Max. Negotiated Rate	$28.02
Rate for Payer: Aetna of NY Commercial	$24.51
Rate for Payer: Aetna of NY Medicare	$16.11
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$14.01
Rate for Payer: Cash Price	$26.26
Rate for Payer: CDPHP Medicare	$12.96
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$28.02
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$28.02
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$28.02
Rate for Payer: EmblemHealth Medicaid	$28.02
Rate for Payer: EmblemHealth Medicare	$11.91
Rate for Payer: EmblemHealth Select Care	$25.21
Rate for Payer: Fidelis Medicare	$14.01
Rate for Payer: Galaxy Health Commercial	$22.76
Rate for Payer: Hamaspik Choice Medicare	$14.01
Rate for Payer: Humana Medicare	$14.01
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$24.51
Rate for Payer: Local 1199SEIU Medicare	$16.11
Rate for Payer: MVP Health Care of NY Commercial	$26.27
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$19.72
Rate for Payer: MVP Health Care of NY Medicare	$14.71
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$5.25
Rate for Payer: United Healthcare Medicare	$14.01
Rate for Payer: WellCare Medicare	$19.26

SHOULDER IMMOB W/FOAM ST XL

Facility

$35.02

Hospital Charge Code	4471344
Hospital Revenue Code	270
Min. Negotiated Rate	$22.76
Max. Negotiated Rate	$22.76
Rate for Payer: Cash Price	$26.26
Rate for Payer: Galaxy Health Commercial	$22.76

SHUNT EVALUATION

Facility

$81.00

Service Code	HCPCS 78645 26
Hospital Charge Code	5210035
Hospital Revenue Code	960
Min. Negotiated Rate	$52.65
Max. Negotiated Rate	$52.65
Rate for Payer: Cash Price	$60.75
Rate for Payer: Galaxy Health Commercial	$52.65

SHUNT EVALUATION

Facility

$81.00

Service Code	HCPCS 78645 26
Hospital Charge Code	5210035
Hospital Revenue Code	960
Min. Negotiated Rate	$12.15
Max. Negotiated Rate	$64.80
Rate for Payer: Aetna of NY Commercial	$56.70
Rate for Payer: Aetna of NY Medicare	$37.26
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$32.40
Rate for Payer: Cash Price	$60.75
Rate for Payer: CDPHP Medicare	$29.97
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$64.80
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$64.80
Rate for Payer: EmblemHealth Medicaid	$64.80
Rate for Payer: EmblemHealth Medicare	$27.54
Rate for Payer: Fidelis Medicare	$32.40
Rate for Payer: Galaxy Health Commercial	$52.65
Rate for Payer: Hamaspik Choice Medicare	$32.40
Rate for Payer: Humana Medicare	$32.40
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$56.70
Rate for Payer: Local 1199SEIU Medicare	$37.26
Rate for Payer: MVP Health Care of NY Commercial	$60.75
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$45.60
Rate for Payer: MVP Health Care of NY Medicare	$34.02
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$12.15
Rate for Payer: United Healthcare Medicare	$32.40
Rate for Payer: WellCare Medicare	$44.55

SHUNT EVALUATION

Facility

$1,664.00

Service Code	HCPCS 78645
Hospital Charge Code	4210035
Hospital Revenue Code	341
Min. Negotiated Rate	$1,081.60
Max. Negotiated Rate	$1,081.60
Rate for Payer: Cash Price	$1,248.00
Rate for Payer: Galaxy Health Commercial	$1,081.60

SHUNT EVALUATION

Facility

$1,664.00

Service Code	HCPCS 78645
Hospital Charge Code	4210035
Hospital Revenue Code	341
Min. Negotiated Rate	$249.60
Max. Negotiated Rate	$1,545.00
Rate for Payer: Aetna of NY Commercial	$1,164.80
Rate for Payer: Aetna of NY Medicare	$765.44
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$665.60
Rate for Payer: Cash Price	$1,248.00
Rate for Payer: Cash Price	$1,248.00
Rate for Payer: CDPHP Medicare	$615.68
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$1,164.80
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$1,331.20
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$1,331.20
Rate for Payer: EmblemHealth Medicaid	$1,331.20
Rate for Payer: EmblemHealth Medicare	$565.76
Rate for Payer: EmblemHealth Select Care	$1,081.60
Rate for Payer: Fidelis Medicare	$665.60
Rate for Payer: Galaxy Health Commercial	$1,081.60
Rate for Payer: Hamaspik Choice Medicare	$665.60
Rate for Payer: Humana Medicare	$665.60
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$1,164.80
Rate for Payer: Local 1199SEIU Medicare	$765.44
Rate for Payer: MVP Health Care of NY Commercial	$1,248.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$936.83
Rate for Payer: MVP Health Care of NY Medicare	$698.88
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$1,545.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$249.60
Rate for Payer: United Healthcare Commercial	$1,545.00
Rate for Payer: United Healthcare Medicare	$665.60
Rate for Payer: WellCare Medicare	$915.20

SHUNTOGRAM FOR INVESTIGATION OF PREVIOUSLY PLACED INDWELLING NONVASCULAR SHUNT (EG, LEVEEN SHUNT, VENTRICULOPERITONEAL SHUNT, INDWELLING INFUSION PUMP), RADIOLOGICAL SUPERVISION AND INTERPRETATION

Facility

$1,900.00

Service Code	CPT 75809
Hospital Revenue Code	490
Min. Negotiated Rate	$104.75
Max. Negotiated Rate	$1,900.00
Rate for Payer: Aetna of NY Commercial	$1,900.00
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$1,900.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$104.75

SILDENAFIL 20 MG TABLET

Facility

$6.18

Service Code	NDC 904667104
Hospital Charge Code	4409160
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

SILDENAFIL 20 MG TABLET

Facility

$6.18

Service Code	NDC 904667104
Hospital Charge Code	4409160
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

SILVER ALGINATE DRESSING

Facility

$63.86

Hospital Charge Code	4479201
Hospital Revenue Code	270
Min. Negotiated Rate	$9.58
Max. Negotiated Rate	$51.09
Rate for Payer: Aetna of NY Commercial	$44.70
Rate for Payer: Aetna of NY Medicare	$29.38
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$25.54
Rate for Payer: Cash Price	$47.90
Rate for Payer: CDPHP Medicare	$23.63
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$51.09
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$51.09
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$51.09
Rate for Payer: EmblemHealth Medicaid	$51.09
Rate for Payer: EmblemHealth Medicare	$21.71
Rate for Payer: EmblemHealth Select Care	$45.98
Rate for Payer: Fidelis Medicare	$25.54
Rate for Payer: Galaxy Health Commercial	$41.51
Rate for Payer: Hamaspik Choice Medicare	$25.54
Rate for Payer: Humana Medicare	$25.54
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$44.70
Rate for Payer: Local 1199SEIU Medicare	$29.38
Rate for Payer: MVP Health Care of NY Commercial	$47.90
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$35.95
Rate for Payer: MVP Health Care of NY Medicare	$26.82
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$9.58
Rate for Payer: United Healthcare Medicare	$25.54
Rate for Payer: WellCare Medicare	$35.12

SILVER ALGINATE DRESSING

Facility

$63.86

Hospital Charge Code	4479194
Hospital Revenue Code	270
Min. Negotiated Rate	$9.58
Max. Negotiated Rate	$51.09
Rate for Payer: Aetna of NY Commercial	$44.70
Rate for Payer: Aetna of NY Medicare	$29.38
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$25.54
Rate for Payer: Cash Price	$47.90
Rate for Payer: CDPHP Medicare	$23.63
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$51.09
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$51.09
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$51.09
Rate for Payer: EmblemHealth Medicaid	$51.09
Rate for Payer: EmblemHealth Medicare	$21.71
Rate for Payer: EmblemHealth Select Care	$45.98
Rate for Payer: Fidelis Medicare	$25.54
Rate for Payer: Galaxy Health Commercial	$41.51
Rate for Payer: Hamaspik Choice Medicare	$25.54
Rate for Payer: Humana Medicare	$25.54
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$44.70
Rate for Payer: Local 1199SEIU Medicare	$29.38
Rate for Payer: MVP Health Care of NY Commercial	$47.90
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$35.95
Rate for Payer: MVP Health Care of NY Medicare	$26.82
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$9.58
Rate for Payer: United Healthcare Medicare	$25.54
Rate for Payer: WellCare Medicare	$35.12

Know your out-of-pocket cost for care.

All Charges