Ellenville Regional Hospital

All Charges

Charge

Type

Setting

Price

TRANSFERRIN

Facility

$38.00

Service Code	HCPCS 84466
Hospital Charge Code	4300790
Hospital Revenue Code	301
Min. Negotiated Rate	$24.70
Max. Negotiated Rate	$24.70
Rate for Payer: Cash Price	$28.50
Rate for Payer: Galaxy Health Commercial	$24.70

TRANSFERRIN

Facility

$38.00

Service Code	HCPCS 84466
Hospital Charge Code	4300790
Hospital Revenue Code	301
Min. Negotiated Rate	$5.70
Max. Negotiated Rate	$30.40
Rate for Payer: Aetna of NY Commercial	$24.70
Rate for Payer: Aetna of NY Medicare	$17.48
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$15.20
Rate for Payer: Cash Price	$28.50
Rate for Payer: CDPHP Medicare	$14.06
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$22.80
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$30.40
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$30.40
Rate for Payer: EmblemHealth Medicaid	$30.40
Rate for Payer: EmblemHealth Medicare	$12.92
Rate for Payer: EmblemHealth Select Care	$22.80
Rate for Payer: Fidelis Medicare	$15.20
Rate for Payer: Galaxy Health Commercial	$24.70
Rate for Payer: Hamaspik Choice Medicare	$15.20
Rate for Payer: Humana Medicare	$15.20
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$24.70
Rate for Payer: Local 1199SEIU Medicare	$17.48
Rate for Payer: MVP Health Care of NY Commercial	$28.50
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$21.39
Rate for Payer: MVP Health Care of NY Medicare	$15.96
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$28.50
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$5.70
Rate for Payer: United Healthcare Commercial	$28.50
Rate for Payer: United Healthcare Medicare	$15.20
Rate for Payer: WellCare Medicare	$20.90

TRANSFUSION-BLOOD OVER 4 HRS

Facility

$1,352.00

Service Code	HCPCS 36430
Hospital Charge Code	4300791
Hospital Revenue Code	391
Min. Negotiated Rate	$676.00
Max. Negotiated Rate	$878.80
Rate for Payer: Cash Price	$1,014.00
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$676.00
Rate for Payer: EmblemHealth Select Care	$676.00
Rate for Payer: Galaxy Health Commercial	$878.80
Rate for Payer: WellCare Medicare	$743.60

TRANSFUSION-BLOOD OVER 4 HRS

Facility

$1,352.00

Service Code	HCPCS 36430
Hospital Charge Code	4300791
Hospital Revenue Code	391
Min. Negotiated Rate	$202.80
Max. Negotiated Rate	$1,081.60
Rate for Payer: Aetna of NY Commercial	$946.40
Rate for Payer: Aetna of NY Medicare	$621.92
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$540.80
Rate for Payer: Cash Price	$1,014.00
Rate for Payer: CDPHP Medicare	$500.24
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$676.00
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$1,081.60
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$1,081.60
Rate for Payer: EmblemHealth Medicaid	$1,081.60
Rate for Payer: EmblemHealth Medicare	$459.68
Rate for Payer: EmblemHealth Select Care	$676.00
Rate for Payer: Fidelis Medicare	$540.80
Rate for Payer: Galaxy Health Commercial	$878.80
Rate for Payer: Hamaspik Choice Medicare	$540.80
Rate for Payer: Humana Medicare	$540.80
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$946.40
Rate for Payer: Local 1199SEIU Medicare	$621.92
Rate for Payer: MVP Health Care of NY Commercial	$1,014.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$761.18
Rate for Payer: MVP Health Care of NY Medicare	$567.84
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$1,014.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$202.80
Rate for Payer: United Healthcare Commercial	$1,014.00
Rate for Payer: United Healthcare Medicare	$540.80
Rate for Payer: WellCare Medicare	$743.60

TRANSFUSION BLOOD UP TO 2 HOURS

Facility

$1,352.00

Service Code	HCPCS 36430
Hospital Charge Code	4450110
Hospital Revenue Code	391
Min. Negotiated Rate	$202.80
Max. Negotiated Rate	$1,081.60
Rate for Payer: Aetna of NY Commercial	$946.40
Rate for Payer: Aetna of NY Medicare	$621.92
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$540.80
Rate for Payer: Cash Price	$1,014.00
Rate for Payer: CDPHP Medicare	$500.24
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$676.00
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$1,081.60
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$1,081.60
Rate for Payer: EmblemHealth Medicaid	$1,081.60
Rate for Payer: EmblemHealth Medicare	$459.68
Rate for Payer: EmblemHealth Select Care	$676.00
Rate for Payer: Fidelis Medicare	$540.80
Rate for Payer: Galaxy Health Commercial	$878.80
Rate for Payer: Hamaspik Choice Medicare	$540.80
Rate for Payer: Humana Medicare	$540.80
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$946.40
Rate for Payer: Local 1199SEIU Medicare	$621.92
Rate for Payer: MVP Health Care of NY Commercial	$1,014.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$761.18
Rate for Payer: MVP Health Care of NY Medicare	$567.84
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$1,014.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$202.80
Rate for Payer: United Healthcare Commercial	$1,014.00
Rate for Payer: United Healthcare Medicare	$540.80
Rate for Payer: WellCare Medicare	$743.60

TRANSFUSION BLOOD UP TO 2 HOURS

Facility

$1,352.00

Service Code	HCPCS 36430
Hospital Charge Code	4450110
Hospital Revenue Code	391
Min. Negotiated Rate	$676.00
Max. Negotiated Rate	$878.80
Rate for Payer: Cash Price	$1,014.00
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$676.00
Rate for Payer: EmblemHealth Select Care	$676.00
Rate for Payer: Galaxy Health Commercial	$878.80
Rate for Payer: WellCare Medicare	$743.60

TRANSFUSION BLOOD UP TO 4 HOURS

Facility

$1,352.00

Service Code	HCPCS 36430
Hospital Charge Code	4450111
Hospital Revenue Code	391
Min. Negotiated Rate	$202.80
Max. Negotiated Rate	$1,081.60
Rate for Payer: Aetna of NY Commercial	$946.40
Rate for Payer: Aetna of NY Medicare	$621.92
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$540.80
Rate for Payer: Cash Price	$1,014.00
Rate for Payer: CDPHP Medicare	$500.24
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$676.00
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$1,081.60
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$1,081.60
Rate for Payer: EmblemHealth Medicaid	$1,081.60
Rate for Payer: EmblemHealth Medicare	$459.68
Rate for Payer: EmblemHealth Select Care	$676.00
Rate for Payer: Fidelis Medicare	$540.80
Rate for Payer: Galaxy Health Commercial	$878.80
Rate for Payer: Hamaspik Choice Medicare	$540.80
Rate for Payer: Humana Medicare	$540.80
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$946.40
Rate for Payer: Local 1199SEIU Medicare	$621.92
Rate for Payer: MVP Health Care of NY Commercial	$1,014.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$761.18
Rate for Payer: MVP Health Care of NY Medicare	$567.84
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$1,014.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$202.80
Rate for Payer: United Healthcare Commercial	$1,014.00
Rate for Payer: United Healthcare Medicare	$540.80
Rate for Payer: WellCare Medicare	$743.60

TRANSFUSION BLOOD UP TO 4 HOURS

Facility

$1,352.00

Service Code	HCPCS 36430
Hospital Charge Code	4450111
Hospital Revenue Code	391
Min. Negotiated Rate	$676.00
Max. Negotiated Rate	$878.80
Rate for Payer: Cash Price	$1,014.00
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$676.00
Rate for Payer: EmblemHealth Select Care	$676.00
Rate for Payer: Galaxy Health Commercial	$878.80
Rate for Payer: WellCare Medicare	$743.60

TRANSFUSION BLOOD UP TO 6 HOURS

Facility

$1,352.00

Service Code	HCPCS 36430
Hospital Charge Code	4450112
Hospital Revenue Code	391
Min. Negotiated Rate	$202.80
Max. Negotiated Rate	$1,081.60
Rate for Payer: Aetna of NY Commercial	$946.40
Rate for Payer: Aetna of NY Medicare	$621.92
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$540.80
Rate for Payer: Cash Price	$1,014.00
Rate for Payer: CDPHP Medicare	$500.24
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$676.00
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$1,081.60
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$1,081.60
Rate for Payer: EmblemHealth Medicaid	$1,081.60
Rate for Payer: EmblemHealth Medicare	$459.68
Rate for Payer: EmblemHealth Select Care	$676.00
Rate for Payer: Fidelis Medicare	$540.80
Rate for Payer: Galaxy Health Commercial	$878.80
Rate for Payer: Hamaspik Choice Medicare	$540.80
Rate for Payer: Humana Medicare	$540.80
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$946.40
Rate for Payer: Local 1199SEIU Medicare	$621.92
Rate for Payer: MVP Health Care of NY Commercial	$1,014.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$761.18
Rate for Payer: MVP Health Care of NY Medicare	$567.84
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$1,014.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$202.80
Rate for Payer: United Healthcare Commercial	$1,014.00
Rate for Payer: United Healthcare Medicare	$540.80
Rate for Payer: WellCare Medicare	$743.60

TRANSFUSION BLOOD UP TO 6 HOURS

Facility

$1,352.00

Service Code	HCPCS 36430
Hospital Charge Code	4450112
Hospital Revenue Code	391
Min. Negotiated Rate	$676.00
Max. Negotiated Rate	$878.80
Rate for Payer: Cash Price	$1,014.00
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$676.00
Rate for Payer: EmblemHealth Select Care	$676.00
Rate for Payer: Galaxy Health Commercial	$878.80
Rate for Payer: WellCare Medicare	$743.60

TRANSFUSION BLOODUP TO 8 HOURS

Facility

$1,352.00

Service Code	HCPCS 36430
Hospital Charge Code	4450113
Hospital Revenue Code	391
Min. Negotiated Rate	$202.80
Max. Negotiated Rate	$1,081.60
Rate for Payer: Aetna of NY Commercial	$946.40
Rate for Payer: Aetna of NY Medicare	$621.92
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$540.80
Rate for Payer: Cash Price	$1,014.00
Rate for Payer: CDPHP Medicare	$500.24
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$676.00
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$1,081.60
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$1,081.60
Rate for Payer: EmblemHealth Medicaid	$1,081.60
Rate for Payer: EmblemHealth Medicare	$459.68
Rate for Payer: EmblemHealth Select Care	$676.00
Rate for Payer: Fidelis Medicare	$540.80
Rate for Payer: Galaxy Health Commercial	$878.80
Rate for Payer: Hamaspik Choice Medicare	$540.80
Rate for Payer: Humana Medicare	$540.80
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$946.40
Rate for Payer: Local 1199SEIU Medicare	$621.92
Rate for Payer: MVP Health Care of NY Commercial	$1,014.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$761.18
Rate for Payer: MVP Health Care of NY Medicare	$567.84
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$1,014.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$202.80
Rate for Payer: United Healthcare Commercial	$1,014.00
Rate for Payer: United Healthcare Medicare	$540.80
Rate for Payer: WellCare Medicare	$743.60

TRANSFUSION BLOODUP TO 8 HOURS

Facility

$1,352.00

Service Code	HCPCS 36430
Hospital Charge Code	4450113
Hospital Revenue Code	391
Min. Negotiated Rate	$676.00
Max. Negotiated Rate	$878.80
Rate for Payer: Cash Price	$1,014.00
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$676.00
Rate for Payer: EmblemHealth Select Care	$676.00
Rate for Payer: Galaxy Health Commercial	$878.80
Rate for Payer: WellCare Medicare	$743.60

TRANSURETHRAL INCISION PROSTATE

Facility

$10,804.00

Service Code	HCPCS 52450
Hospital Charge Code	4002032
Hospital Revenue Code	490
Min. Negotiated Rate	$1,620.60
Max. Negotiated Rate	$8,643.20
Rate for Payer: Aetna of NY Commercial	$1,900.00
Rate for Payer: Aetna of NY Medicare	$4,969.84
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$4,321.60
Rate for Payer: Cash Price	$8,103.00
Rate for Payer: Cash Price	$8,103.00
Rate for Payer: CDPHP Medicare	$3,997.48
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$8,643.20
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$8,643.20
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$8,643.20
Rate for Payer: EmblemHealth Medicaid	$8,643.20
Rate for Payer: EmblemHealth Medicare	$3,673.36
Rate for Payer: EmblemHealth Select Care	$7,778.88
Rate for Payer: Fidelis Medicare	$4,321.60
Rate for Payer: Galaxy Health Commercial	$7,022.60
Rate for Payer: Hamaspik Choice Medicare	$4,321.60
Rate for Payer: Humana Medicare	$4,321.60
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$1,900.00
Rate for Payer: Local 1199SEIU Medicare	$4,969.84
Rate for Payer: Multiplan Commercial	$8,643.20
Rate for Payer: MVP Health Care of NY Commercial	$8,103.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$6,082.65
Rate for Payer: MVP Health Care of NY Medicare	$4,537.68
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$2,097.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$1,620.60
Rate for Payer: United Healthcare Commercial	$2,097.00
Rate for Payer: United Healthcare Medicare	$4,321.60
Rate for Payer: WellCare Medicare	$5,942.20

TRANSURETHRAL INCISION PROSTATE

Facility

$10,804.00

Service Code	HCPCS 52450
Hospital Charge Code	4002032
Hospital Revenue Code	490
Min. Negotiated Rate	$7,022.60
Max. Negotiated Rate	$7,022.60
Rate for Payer: Cash Price	$8,103.00
Rate for Payer: Galaxy Health Commercial	$7,022.60

TRAY,IRRIGATION W/60 CC BULB

Facility

$4.12

Hospital Charge Code	4471628
Hospital Revenue Code	270
Min. Negotiated Rate	$2.68
Max. Negotiated Rate	$2.68
Rate for Payer: Cash Price	$3.09
Rate for Payer: Galaxy Health Commercial	$2.68

TRAY,IRRIGATION W/60 CC BULB

Facility

$4.12

Hospital Charge Code	4471628
Hospital Revenue Code	270
Min. Negotiated Rate	$0.62
Max. Negotiated Rate	$3.30
Rate for Payer: Aetna of NY Commercial	$2.88
Rate for Payer: Aetna of NY Medicare	$1.90
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$1.65
Rate for Payer: Cash Price	$3.09
Rate for Payer: CDPHP Medicare	$1.52
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$3.30
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$3.30
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$3.30
Rate for Payer: EmblemHealth Medicaid	$3.30
Rate for Payer: EmblemHealth Medicare	$1.40
Rate for Payer: EmblemHealth Select Care	$2.97
Rate for Payer: Fidelis Medicare	$1.65
Rate for Payer: Galaxy Health Commercial	$2.68
Rate for Payer: Hamaspik Choice Medicare	$1.65
Rate for Payer: Humana Medicare	$1.65
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$2.88
Rate for Payer: Local 1199SEIU Medicare	$1.90
Rate for Payer: MVP Health Care of NY Commercial	$3.09
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$2.32
Rate for Payer: MVP Health Care of NY Medicare	$1.73
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$0.62
Rate for Payer: United Healthcare Medicare	$1.65
Rate for Payer: WellCare Medicare	$2.27

TRAZODONE HCL 50MG TABS 100 EA

Facility

$6.18

Service Code	NDC 50111043301
Hospital Charge Code	4400770
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

TRAZODONE HCL 50MG TABS 100 EA

Facility

$6.18

Service Code	NDC 50111043301
Hospital Charge Code	4400770
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

TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; WITH PACKING

Facility

$1,246.00

Service Code	HCPCS 12021
Hospital Charge Code	4850304
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

TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; WITH PACKING

Facility

$1,246.00

Service Code	HCPCS 12021
Hospital Charge Code	4850304
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

TREATMENT SPEECH LANGUAGE VOICE AUD IND

Facility

$318.00

Service Code	HCPCS 92507 GN
Hospital Charge Code	4670084
Hospital Revenue Code	440
Min. Negotiated Rate	$206.70
Max. Negotiated Rate	$206.70
Rate for Payer: Cash Price	$238.50
Rate for Payer: Galaxy Health Commercial	$206.70

TREATMENT SPEECH LANGUAGE VOICE AUD IND

Facility

$318.00

Service Code	HCPCS 92507 GN
Hospital Charge Code	4670084
Hospital Revenue Code	440
Min. Negotiated Rate	$47.70
Max. Negotiated Rate	$254.40
Rate for Payer: Aetna of NY Commercial	$115.00
Rate for Payer: Aetna of NY Medicare	$146.28
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$127.20
Rate for Payer: Cash Price	$238.50
Rate for Payer: Cash Price	$238.50
Rate for Payer: Cash Price	$238.50
Rate for Payer: CDPHP Medicare	$117.66
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$254.40
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$254.40
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$254.40
Rate for Payer: EmblemHealth Medicaid	$254.40
Rate for Payer: EmblemHealth Medicare	$108.12
Rate for Payer: EmblemHealth Select Care	$228.96
Rate for Payer: Fidelis Medicare	$127.20
Rate for Payer: Galaxy Health Commercial	$206.70
Rate for Payer: Hamaspik Choice Medicare	$127.20
Rate for Payer: Humana Medicare	$127.20
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$115.00
Rate for Payer: Local 1199SEIU Medicare	$146.28
Rate for Payer: MVP Health Care of NY Commercial	$187.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$141.00
Rate for Payer: MVP Health Care of NY Medicare	$133.56
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$161.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$47.70
Rate for Payer: United Healthcare Commercial	$161.00
Rate for Payer: United Healthcare Medicare	$127.20
Rate for Payer: WellCare Medicare	$174.90

TREATMENT SPEECH LANGUAGE VOICE AUD IND (MOD 59)

Facility

$318.00

Service Code	HCPCS 92507 GN,59
Hospital Charge Code	4670292
Hospital Revenue Code	440
Min. Negotiated Rate	$47.70
Max. Negotiated Rate	$254.40
Rate for Payer: Aetna of NY Commercial	$115.00
Rate for Payer: Aetna of NY Medicare	$146.28
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$127.20
Rate for Payer: Cash Price	$238.50
Rate for Payer: Cash Price	$238.50
Rate for Payer: Cash Price	$238.50
Rate for Payer: CDPHP Medicare	$117.66
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$254.40
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$254.40
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$254.40
Rate for Payer: EmblemHealth Medicaid	$254.40
Rate for Payer: EmblemHealth Medicare	$108.12
Rate for Payer: EmblemHealth Select Care	$228.96
Rate for Payer: Fidelis Medicare	$127.20
Rate for Payer: Galaxy Health Commercial	$206.70
Rate for Payer: Hamaspik Choice Medicare	$127.20
Rate for Payer: Humana Medicare	$127.20
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$115.00
Rate for Payer: Local 1199SEIU Medicare	$146.28
Rate for Payer: MVP Health Care of NY Commercial	$187.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$141.00
Rate for Payer: MVP Health Care of NY Medicare	$133.56
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$161.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$47.70
Rate for Payer: United Healthcare Commercial	$161.00
Rate for Payer: United Healthcare Medicare	$127.20
Rate for Payer: WellCare Medicare	$174.90

TREATMENT SPEECH LANGUAGE VOICE AUD IND (MOD 59)

Facility

$318.00

Service Code	HCPCS 92507 GN,59
Hospital Charge Code	4670292
Hospital Revenue Code	440
Min. Negotiated Rate	$206.70
Max. Negotiated Rate	$206.70
Rate for Payer: Cash Price	$238.50
Rate for Payer: Galaxy Health Commercial	$206.70

TREATMENT SPEECH LANGUAGE VOICE AUD IND (MOD 59 W KX)

Facility

$318.00

Service Code	HCPCS 92507 GN,59,KX
Hospital Charge Code	4670308
Hospital Revenue Code	440
Min. Negotiated Rate	$206.70
Max. Negotiated Rate	$206.70
Rate for Payer: Cash Price	$238.50
Rate for Payer: Galaxy Health Commercial	$206.70

Know your out-of-pocket cost for care.

All Charges