Ellenville Regional Hospital

All Charges

Charge

Type

Setting

Price

THER INT COG FUNC EA ADD 15 MIN (W/ KX)

Facility

$83.00

Service Code	HCPCS 97130 GN,KX
Hospital Charge Code	4670280
Hospital Revenue Code	440
Min. Negotiated Rate	$12.45
Max. Negotiated Rate	$187.00
Rate for Payer: Aetna of NY Commercial	$115.00
Rate for Payer: Aetna of NY Medicare	$38.18
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$33.20
Rate for Payer: Cash Price	$62.25
Rate for Payer: Cash Price	$62.25
Rate for Payer: Cash Price	$62.25
Rate for Payer: CDPHP Medicare	$30.71
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$66.40
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$56.50
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$47.08
Rate for Payer: EmblemHealth Medicaid	$47.08
Rate for Payer: EmblemHealth Medicare	$28.22
Rate for Payer: EmblemHealth Select Care	$59.76
Rate for Payer: Fidelis Medicare	$33.20
Rate for Payer: Galaxy Health Commercial	$53.95
Rate for Payer: Galaxy Health Workers Comp	$46.14
Rate for Payer: Hamaspik Choice Medicaid	$47.08
Rate for Payer: Hamaspik Choice Medicare	$33.20
Rate for Payer: Humana Medicare	$33.20
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$115.00
Rate for Payer: Local 1199SEIU Medicare	$38.18
Rate for Payer: MVP Health Care of NY Child Health Plus/Family Health Plus/HARP/Medicaid	$49.43
Rate for Payer: MVP Health Care of NY Commercial	$187.00
Rate for Payer: MVP Health Care of NY Essential Plan 1&2	$101.22
Rate for Payer: MVP Health Care of NY Essential Plan 3&4	$101.22
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$141.00
Rate for Payer: MVP Health Care of NY Medicare	$34.86
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$161.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$12.45
Rate for Payer: United Healthcare Commercial	$161.00
Rate for Payer: United Healthcare Medicare	$33.20
Rate for Payer: WellCare Child Health Plus/Family Health Plus/Medicaid	$49.43
Rate for Payer: WellCare Medicare	$45.65

THER/PROPH/DIAG IV INF INIT =<1 HR

Facility

$652.00

Service Code	HCPCS 96365
Hospital Charge Code	4450105
Hospital Revenue Code	260
Min. Negotiated Rate	$423.80
Max. Negotiated Rate	$423.80
Rate for Payer: Cash Price	$489.00
Rate for Payer: Galaxy Health Commercial	$423.80

THER/PROPH/DIAG IV INF INIT =<1 HR

Facility

$652.00

Service Code	HCPCS 96365
Hospital Charge Code	4450105
Hospital Revenue Code	260
Min. Negotiated Rate	$97.80
Max. Negotiated Rate	$521.60
Rate for Payer: Aetna of NY Commercial	$456.40
Rate for Payer: Aetna of NY Medicare	$299.92
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$260.80
Rate for Payer: Cash Price	$489.00
Rate for Payer: CDPHP Medicare	$241.24
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$521.60
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$521.60
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$521.60
Rate for Payer: EmblemHealth Medicaid	$521.60
Rate for Payer: EmblemHealth Medicare	$221.68
Rate for Payer: EmblemHealth Select Care	$469.44
Rate for Payer: Fidelis Medicare	$260.80
Rate for Payer: Galaxy Health Commercial	$423.80
Rate for Payer: Hamaspik Choice Medicare	$260.80
Rate for Payer: Humana Medicare	$260.80
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$456.40
Rate for Payer: Local 1199SEIU Medicare	$299.92
Rate for Payer: MVP Health Care of NY Commercial	$489.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$367.08
Rate for Payer: MVP Health Care of NY Medicare	$273.84
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$489.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$97.80
Rate for Payer: United Healthcare Commercial	$489.00
Rate for Payer: United Healthcare Medicare	$260.80
Rate for Payer: WellCare Medicare	$358.60

THIAMINE HCL 100 MG INJ

Facility

$38.37

Service Code	HCPCS J3411
Hospital Charge Code	4400756
Hospital Revenue Code	636
Min. Negotiated Rate	$1.55
Max. Negotiated Rate	$24.94
Rate for Payer: Aetna of NY Commercial	$21.10
Rate for Payer: Cash Price	$28.78
Rate for Payer: Cash Price	$28.78
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$1.55
Rate for Payer: EmblemHealth Select Care	$1.55
Rate for Payer: Galaxy Health Commercial	$24.94
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$21.10
Rate for Payer: WellCare Medicare	$21.10

THIAMINE HCL 100 MG INJ

Facility

$38.37

Service Code	HCPCS J3411
Hospital Charge Code	4400756
Hospital Revenue Code	636
Min. Negotiated Rate	$1.55
Max. Negotiated Rate	$30.70
Rate for Payer: Aetna of NY Medicare	$17.65
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$15.35
Rate for Payer: Cash Price	$28.78
Rate for Payer: Cash Price	$28.78
Rate for Payer: CDPHP Medicare	$14.20
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$1.55
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$30.70
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$30.70
Rate for Payer: EmblemHealth Medicaid	$30.70
Rate for Payer: EmblemHealth Medicare	$13.05
Rate for Payer: EmblemHealth Select Care	$1.55
Rate for Payer: Fidelis Medicare	$15.35
Rate for Payer: Galaxy Health Commercial	$24.94
Rate for Payer: Hamaspik Choice Medicare	$15.35
Rate for Payer: Humana Medicare	$15.35
Rate for Payer: Local 1199SEIU Medicare	$17.65
Rate for Payer: MVP Health Care of NY Commercial	$28.78
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$21.60
Rate for Payer: MVP Health Care of NY Medicare	$16.12
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$4.13
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$5.76
Rate for Payer: United Healthcare Commercial	$4.13
Rate for Payer: United Healthcare Medicare	$15.35
Rate for Payer: WellCare Medicare	$21.10

THORACENTESIS ASPIRATE PLEURA WO IMAGING

Facility

$1,923.00

Service Code	HCPCS 32554
Hospital Charge Code	4602224
Hospital Revenue Code	450
Min. Negotiated Rate	$288.45
Max. Negotiated Rate	$1,538.40
Rate for Payer: Aetna of NY Commercial	$1,000.00
Rate for Payer: Aetna of NY Medicare	$884.58
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$769.20
Rate for Payer: Cash Price	$1,442.25
Rate for Payer: Cash Price	$1,442.25
Rate for Payer: Cash Price	$1,442.25
Rate for Payer: CDPHP Medicare	$711.51
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$1,206.00
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$1,538.40
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$1,538.40
Rate for Payer: EmblemHealth Medicaid	$1,538.40
Rate for Payer: EmblemHealth Medicare	$653.82
Rate for Payer: EmblemHealth Select Care	$1,085.00
Rate for Payer: Fidelis Medicare	$769.20
Rate for Payer: Galaxy Health Commercial	$1,249.95
Rate for Payer: Hamaspik Choice Medicare	$769.20
Rate for Payer: Humana Medicare	$769.20
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$1,000.00
Rate for Payer: Local 1199SEIU Medicare	$884.58
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	$807.66
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$1,009.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$288.45
Rate for Payer: United Healthcare Commercial	$1,009.00
Rate for Payer: United Healthcare Medicare	$769.20
Rate for Payer: WellCare Medicare	$1,057.65

THORACENTESIS ASPIRATE PLEURA WO IMAGING

Facility

$1,923.00

Service Code	HCPCS 32554
Hospital Charge Code	4602224
Hospital Revenue Code	450
Min. Negotiated Rate	$1,249.95
Max. Negotiated Rate	$1,249.95
Rate for Payer: Cash Price	$1,442.25
Rate for Payer: Galaxy Health Commercial	$1,249.95

THORACENTESIS NEEDLE/CATH PLEURA W/IMAGING

Facility

$335.00

Service Code	HCPCS 32555 26
Hospital Charge Code	5201082
Hospital Revenue Code	960
Min. Negotiated Rate	$217.75
Max. Negotiated Rate	$217.75
Rate for Payer: Cash Price	$251.25
Rate for Payer: Galaxy Health Commercial	$217.75

THORACENTESIS NEEDLE/CATH PLEURA W/IMAGING

Facility

$1,923.00

Service Code	HCPCS 32555
Hospital Charge Code	4201082
Hospital Revenue Code	402
Min. Negotiated Rate	$288.45
Max. Negotiated Rate	$1,538.40
Rate for Payer: Aetna of NY Commercial	$1,346.10
Rate for Payer: Aetna of NY Medicare	$884.58
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$769.20
Rate for Payer: Cash Price	$1,442.25
Rate for Payer: Cash Price	$1,442.25
Rate for Payer: CDPHP Medicare	$711.51
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$1,346.10
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$1,538.40
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$1,538.40
Rate for Payer: EmblemHealth Medicaid	$1,538.40
Rate for Payer: EmblemHealth Medicare	$653.82
Rate for Payer: EmblemHealth Select Care	$1,249.95
Rate for Payer: Fidelis Medicare	$769.20
Rate for Payer: Galaxy Health Commercial	$1,249.95
Rate for Payer: Hamaspik Choice Medicare	$769.20
Rate for Payer: Humana Medicare	$769.20
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$1,346.10
Rate for Payer: Local 1199SEIU Medicare	$884.58
Rate for Payer: MVP Health Care of NY Commercial	$1,442.25
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$1,082.65
Rate for Payer: MVP Health Care of NY Medicare	$807.66
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$489.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$288.45
Rate for Payer: United Healthcare Commercial	$489.00
Rate for Payer: United Healthcare Medicare	$769.20
Rate for Payer: WellCare Medicare	$1,057.65

THORACENTESIS NEEDLE/CATH PLEURA W/IMAGING

Facility

$1,923.00

Service Code	HCPCS 32555
Hospital Charge Code	4201082
Hospital Revenue Code	402
Min. Negotiated Rate	$1,249.95
Max. Negotiated Rate	$1,249.95
Rate for Payer: Cash Price	$1,442.25
Rate for Payer: Galaxy Health Commercial	$1,249.95

THORACENTESIS NEEDLE/CATH PLEURA W/IMAGING

Facility

$335.00

Service Code	HCPCS 32555 26
Hospital Charge Code	5201082
Hospital Revenue Code	960
Min. Negotiated Rate	$50.25
Max. Negotiated Rate	$268.00
Rate for Payer: Aetna of NY Commercial	$234.50
Rate for Payer: Aetna of NY Medicare	$154.10
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$134.00
Rate for Payer: Cash Price	$251.25
Rate for Payer: CDPHP Medicare	$123.95
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$268.00
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$268.00
Rate for Payer: EmblemHealth Medicaid	$268.00
Rate for Payer: EmblemHealth Medicare	$113.90
Rate for Payer: Fidelis Medicare	$134.00
Rate for Payer: Galaxy Health Commercial	$217.75
Rate for Payer: Hamaspik Choice Medicare	$134.00
Rate for Payer: Humana Medicare	$134.00
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$234.50
Rate for Payer: Local 1199SEIU Medicare	$154.10
Rate for Payer: MVP Health Care of NY Commercial	$251.25
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$188.60
Rate for Payer: MVP Health Care of NY Medicare	$140.70
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$50.25
Rate for Payer: United Healthcare Medicare	$134.00
Rate for Payer: WellCare Medicare	$184.25

THORACENTESIS TRAY 16GAX3

Facility

$60.77

Hospital Charge Code	4471224
Hospital Revenue Code	270
Min. Negotiated Rate	$39.50
Max. Negotiated Rate	$39.50
Rate for Payer: Cash Price	$45.58
Rate for Payer: Galaxy Health Commercial	$39.50

THORACENTESIS TRAY 16GAX3

Facility

$60.77

Hospital Charge Code	4471224
Hospital Revenue Code	270
Min. Negotiated Rate	$9.12
Max. Negotiated Rate	$48.62
Rate for Payer: Aetna of NY Commercial	$42.54
Rate for Payer: Aetna of NY Medicare	$27.95
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$24.31
Rate for Payer: Cash Price	$45.58
Rate for Payer: CDPHP Medicare	$22.48
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$48.62
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$48.62
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$48.62
Rate for Payer: EmblemHealth Medicaid	$48.62
Rate for Payer: EmblemHealth Medicare	$20.66
Rate for Payer: EmblemHealth Select Care	$43.75
Rate for Payer: Fidelis Medicare	$24.31
Rate for Payer: Galaxy Health Commercial	$39.50
Rate for Payer: Hamaspik Choice Medicare	$24.31
Rate for Payer: Humana Medicare	$24.31
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$42.54
Rate for Payer: Local 1199SEIU Medicare	$27.95
Rate for Payer: MVP Health Care of NY Commercial	$45.58
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$34.21
Rate for Payer: MVP Health Care of NY Medicare	$25.52
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$9.12
Rate for Payer: United Healthcare Medicare	$24.31
Rate for Payer: WellCare Medicare	$33.42

THORACIC RF KIT:THK-17-75

Facility

$3,131.20

Hospital Charge Code	4479207
Hospital Revenue Code	270
Min. Negotiated Rate	$2,035.28
Max. Negotiated Rate	$2,035.28
Rate for Payer: Cash Price	$2,348.40
Rate for Payer: Galaxy Health Commercial	$2,035.28

THORACIC RF KIT:THK-17-75

Facility

$3,131.20

Hospital Charge Code	4479207
Hospital Revenue Code	270
Min. Negotiated Rate	$469.68
Max. Negotiated Rate	$2,504.96
Rate for Payer: Aetna of NY Commercial	$2,191.84
Rate for Payer: Aetna of NY Medicare	$1,440.35
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$1,252.48
Rate for Payer: Cash Price	$2,348.40
Rate for Payer: CDPHP Medicare	$1,158.54
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$2,504.96
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$2,504.96
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$2,504.96
Rate for Payer: EmblemHealth Medicaid	$2,504.96
Rate for Payer: EmblemHealth Medicare	$1,064.61
Rate for Payer: EmblemHealth Select Care	$2,254.46
Rate for Payer: Fidelis Medicare	$1,252.48
Rate for Payer: Galaxy Health Commercial	$2,035.28
Rate for Payer: Hamaspik Choice Medicare	$1,252.48
Rate for Payer: Humana Medicare	$1,252.48
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$2,191.84
Rate for Payer: Local 1199SEIU Medicare	$1,440.35
Rate for Payer: MVP Health Care of NY Commercial	$2,348.40
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$1,762.87
Rate for Payer: MVP Health Care of NY Medicare	$1,315.10
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$469.68
Rate for Payer: United Healthcare Medicare	$1,252.48
Rate for Payer: WellCare Medicare	$1,722.16

THREE PHASE BONE SCAN

Facility

$1,225.00

Service Code	HCPCS 78315
Hospital Charge Code	4210037
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

THREE PHASE BONE SCAN

Facility

$1,225.00

Service Code	HCPCS 78315
Hospital Charge Code	4210037
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

THREE PHASE BONE SCAN

Facility

$147.00

Service Code	HCPCS 78315 26
Hospital Charge Code	5210037
Hospital Revenue Code	960
Min. Negotiated Rate	$22.05
Max. Negotiated Rate	$117.60
Rate for Payer: Aetna of NY Commercial	$102.90
Rate for Payer: Aetna of NY Medicare	$67.62
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$58.80
Rate for Payer: Cash Price	$110.25
Rate for Payer: CDPHP Medicare	$54.39
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$117.60
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$117.60
Rate for Payer: EmblemHealth Medicaid	$117.60
Rate for Payer: EmblemHealth Medicare	$49.98
Rate for Payer: Fidelis Medicare	$58.80
Rate for Payer: Galaxy Health Commercial	$95.55
Rate for Payer: Hamaspik Choice Medicare	$58.80
Rate for Payer: Humana Medicare	$58.80
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$102.90
Rate for Payer: Local 1199SEIU Medicare	$67.62
Rate for Payer: MVP Health Care of NY Commercial	$110.25
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$82.76
Rate for Payer: MVP Health Care of NY Medicare	$61.74
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$22.05
Rate for Payer: United Healthcare Medicare	$58.80
Rate for Payer: WellCare Medicare	$80.85

THREE PHASE BONE SCAN

Facility

$147.00

Service Code	HCPCS 78315 26
Hospital Charge Code	5210037
Hospital Revenue Code	960
Min. Negotiated Rate	$95.55
Max. Negotiated Rate	$95.55
Rate for Payer: Cash Price	$110.25
Rate for Payer: Galaxy Health Commercial	$95.55

THROMBIN 5MU PWVL 1 EA

Facility

$266.00

Service Code	NDC 60793021505
Hospital Charge Code	4400758
Hospital Revenue Code	250
Min. Negotiated Rate	$146.30
Max. Negotiated Rate	$172.90
Rate for Payer: Cash Price	$199.50
Rate for Payer: Galaxy Health Commercial	$172.90
Rate for Payer: WellCare Medicare	$146.30

THROMBIN 5MU PWVL 1 EA

Facility

$266.00

Service Code	NDC 60793021505
Hospital Charge Code	4400758
Hospital Revenue Code	250
Min. Negotiated Rate	$39.90
Max. Negotiated Rate	$212.80
Rate for Payer: Aetna of NY Commercial	$186.20
Rate for Payer: Aetna of NY Medicare	$122.36
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$106.40
Rate for Payer: Cash Price	$199.50
Rate for Payer: CDPHP Medicare	$98.42
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$212.80
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$212.80
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$212.80
Rate for Payer: EmblemHealth Medicaid	$212.80
Rate for Payer: EmblemHealth Medicare	$90.44
Rate for Payer: EmblemHealth Select Care	$191.52
Rate for Payer: Fidelis Medicare	$106.40
Rate for Payer: Galaxy Health Commercial	$172.90
Rate for Payer: Hamaspik Choice Medicare	$106.40
Rate for Payer: Humana Medicare	$106.40
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$186.20
Rate for Payer: Local 1199SEIU Medicare	$122.36
Rate for Payer: MVP Health Care of NY Commercial	$199.50
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$149.76
Rate for Payer: MVP Health Care of NY Medicare	$111.72
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$39.90
Rate for Payer: United Healthcare Medicare	$106.40
Rate for Payer: WellCare Medicare	$146.30

THROMBIN TIME

Facility

$17.00

Service Code	HCPCS 85670
Hospital Charge Code	4300770
Hospital Revenue Code	305
Min. Negotiated Rate	$11.05
Max. Negotiated Rate	$11.05
Rate for Payer: Cash Price	$12.75
Rate for Payer: Galaxy Health Commercial	$11.05

THROMBIN TIME

Facility

$17.00

Service Code	HCPCS 85670
Hospital Charge Code	4300770
Hospital Revenue Code	305
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$13.60
Rate for Payer: Aetna of NY Commercial	$11.05
Rate for Payer: Aetna of NY Medicare	$7.82
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$6.80
Rate for Payer: Cash Price	$12.75
Rate for Payer: CDPHP Medicare	$6.29
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$10.20
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$13.60
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$13.60
Rate for Payer: EmblemHealth Medicaid	$13.60
Rate for Payer: EmblemHealth Medicare	$5.78
Rate for Payer: EmblemHealth Select Care	$10.20
Rate for Payer: Fidelis Medicare	$6.80
Rate for Payer: Galaxy Health Commercial	$11.05
Rate for Payer: Hamaspik Choice Medicare	$6.80
Rate for Payer: Humana Medicare	$6.80
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$11.05
Rate for Payer: Local 1199SEIU Medicare	$7.82
Rate for Payer: MVP Health Care of NY Commercial	$12.75
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$9.57
Rate for Payer: MVP Health Care of NY Medicare	$7.14
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$12.75
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$2.55
Rate for Payer: United Healthcare Commercial	$12.75
Rate for Payer: United Healthcare Medicare	$6.80
Rate for Payer: WellCare Medicare	$9.35

THYROID 15MG TABS 100 EA

Facility

$6.18

Service Code	NDC 456045701
Hospital Charge Code	4400071
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

THYROID 15MG TABS 100 EA

Facility

$6.18

Service Code	NDC 456045701
Hospital Charge Code	4400071
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

Know your out-of-pocket cost for care.

All Charges