Ellenville Regional Hospital

All Charges

Charge

Type

Setting

Price

TRULICITY 1.5 MG/0.5 ML PEN 0.5 ML, 0.5 ML

Facility

$739.54

Hospital Charge Code	4404330
Hospital Revenue Code	250
Min. Negotiated Rate	$406.75
Max. Negotiated Rate	$480.70
Rate for Payer: Cash Price	$554.66
Rate for Payer: Galaxy Health Commercial	$480.70
Rate for Payer: WellCare Medicare	$406.75

TRUVADA 200/300 TABLET

Facility

$201.00

Service Code	NDC 61958070101
Hospital Charge Code	4401290
Hospital Revenue Code	250
Min. Negotiated Rate	$110.55
Max. Negotiated Rate	$130.65
Rate for Payer: Cash Price	$150.75
Rate for Payer: Galaxy Health Commercial	$130.65
Rate for Payer: WellCare Medicare	$110.55

TRUVADA 200/300 TABLET

Facility

$201.00

Service Code	NDC 61958070101
Hospital Charge Code	4401290
Hospital Revenue Code	250
Min. Negotiated Rate	$30.15
Max. Negotiated Rate	$160.80
Rate for Payer: Aetna of NY Commercial	$140.70
Rate for Payer: Aetna of NY Medicare	$92.46
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$80.40
Rate for Payer: Cash Price	$150.75
Rate for Payer: CDPHP Medicare	$74.37
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$160.80
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$160.80
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$160.80
Rate for Payer: EmblemHealth Medicaid	$160.80
Rate for Payer: EmblemHealth Medicare	$68.34
Rate for Payer: EmblemHealth Select Care	$144.72
Rate for Payer: Fidelis Medicare	$80.40
Rate for Payer: Galaxy Health Commercial	$130.65
Rate for Payer: Hamaspik Choice Medicare	$80.40
Rate for Payer: Humana Medicare	$80.40
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$140.70
Rate for Payer: Local 1199SEIU Medicare	$92.46
Rate for Payer: MVP Health Care of NY Commercial	$150.75
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$113.16
Rate for Payer: MVP Health Care of NY Medicare	$84.42
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$30.15
Rate for Payer: United Healthcare Medicare	$80.40
Rate for Payer: WellCare Medicare	$110.55

TTE CONG ABN; LIMITED/F-UP

Facility

$1,675.00

Service Code	HCPCS 93304
Hospital Charge Code	4480110
Hospital Revenue Code	480
Min. Negotiated Rate	$251.25
Max. Negotiated Rate	$1,340.00
Rate for Payer: Aetna of NY Commercial	$1,088.75
Rate for Payer: Aetna of NY Medicare	$770.50
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$670.00
Rate for Payer: Cash Price	$1,256.25
Rate for Payer: CDPHP Medicare	$619.75
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$1,172.50
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$1,340.00
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$1,340.00
Rate for Payer: EmblemHealth Medicaid	$1,340.00
Rate for Payer: EmblemHealth Medicare	$569.50
Rate for Payer: EmblemHealth Select Care	$1,088.75
Rate for Payer: Fidelis Medicare	$670.00
Rate for Payer: Galaxy Health Commercial	$1,088.75
Rate for Payer: Hamaspik Choice Medicare	$670.00
Rate for Payer: Humana Medicare	$670.00
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$1,088.75
Rate for Payer: Local 1199SEIU Medicare	$770.50
Rate for Payer: MVP Health Care of NY Commercial	$1,256.25
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$943.02
Rate for Payer: MVP Health Care of NY Medicare	$703.50
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$1,256.25
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$251.25
Rate for Payer: United Healthcare Commercial	$1,256.25
Rate for Payer: United Healthcare Medicare	$670.00
Rate for Payer: WellCare Medicare	$921.25

TTE CONG ABN; LIMITED/F-UP

Facility

$1,675.00

Service Code	HCPCS 93304
Hospital Charge Code	4480110
Hospital Revenue Code	480
Min. Negotiated Rate	$1,088.75
Max. Negotiated Rate	$1,088.75
Rate for Payer: Cash Price	$1,256.25
Rate for Payer: Galaxy Health Commercial	$1,088.75

TTE W OR WO FOL WCON DOPPLER

Facility

$2,403.00

Service Code	HCPCS C8929 TC
Hospital Charge Code	4480106
Hospital Revenue Code	480
Min. Negotiated Rate	$1,561.95
Max. Negotiated Rate	$1,561.95
Rate for Payer: Cash Price	$1,802.25
Rate for Payer: Galaxy Health Commercial	$1,561.95

TTE W OR WO FOL WCON DOPPLER

Facility

$2,403.00

Service Code	HCPCS C8929 TC
Hospital Charge Code	4480106
Hospital Revenue Code	480
Min. Negotiated Rate	$360.45
Max. Negotiated Rate	$1,922.40
Rate for Payer: Aetna of NY Commercial	$1,682.10
Rate for Payer: Aetna of NY Medicare	$1,105.38
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$961.20
Rate for Payer: Cash Price	$1,802.25
Rate for Payer: CDPHP Medicare	$889.11
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$1,682.10
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$1,922.40
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$1,922.40
Rate for Payer: EmblemHealth Medicaid	$1,922.40
Rate for Payer: EmblemHealth Medicare	$817.02
Rate for Payer: EmblemHealth Select Care	$1,561.95
Rate for Payer: Fidelis Medicare	$961.20
Rate for Payer: Galaxy Health Commercial	$1,561.95
Rate for Payer: Hamaspik Choice Medicare	$961.20
Rate for Payer: Humana Medicare	$961.20
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$1,682.10
Rate for Payer: Local 1199SEIU Medicare	$1,105.38
Rate for Payer: MVP Health Care of NY Commercial	$1,802.25
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$1,352.89
Rate for Payer: MVP Health Care of NY Medicare	$1,009.26
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$1,802.25
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$360.45
Rate for Payer: United Healthcare Commercial	$1,802.25
Rate for Payer: United Healthcare Medicare	$961.20
Rate for Payer: WellCare Medicare	$1,321.65

TTE W OR W/O FOL W/CONT COM

Facility

$2,403.00

Service Code	HCPCS C8921
Hospital Charge Code	4480103
Hospital Revenue Code	480
Min. Negotiated Rate	$360.45
Max. Negotiated Rate	$1,922.40
Rate for Payer: Aetna of NY Commercial	$1,682.10
Rate for Payer: Aetna of NY Medicare	$1,105.38
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$961.20
Rate for Payer: Cash Price	$1,802.25
Rate for Payer: CDPHP Medicare	$889.11
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$1,682.10
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$1,922.40
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$1,922.40
Rate for Payer: EmblemHealth Medicaid	$1,922.40
Rate for Payer: EmblemHealth Medicare	$817.02
Rate for Payer: EmblemHealth Select Care	$1,561.95
Rate for Payer: Fidelis Medicare	$961.20
Rate for Payer: Galaxy Health Commercial	$1,561.95
Rate for Payer: Hamaspik Choice Medicare	$961.20
Rate for Payer: Humana Medicare	$961.20
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$1,682.10
Rate for Payer: Local 1199SEIU Medicare	$1,105.38
Rate for Payer: MVP Health Care of NY Commercial	$1,802.25
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$1,352.89
Rate for Payer: MVP Health Care of NY Medicare	$1,009.26
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$1,802.25
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$360.45
Rate for Payer: United Healthcare Commercial	$1,802.25
Rate for Payer: United Healthcare Medicare	$961.20
Rate for Payer: WellCare Medicare	$1,321.65

TTE W OR W/O FOL W/CONT COM

Facility

$2,403.00

Service Code	HCPCS C8921
Hospital Charge Code	4480103
Hospital Revenue Code	480
Min. Negotiated Rate	$1,561.95
Max. Negotiated Rate	$1,561.95
Rate for Payer: Cash Price	$1,802.25
Rate for Payer: Galaxy Health Commercial	$1,561.95

TUBERCULIN PURIF PROT DERIV 5TU/0.1ML MD

Facility

$22.92

Service Code	NDC 42023010401
Hospital Charge Code	4400064
Hospital Revenue Code	250
Min. Negotiated Rate	$3.44
Max. Negotiated Rate	$18.34
Rate for Payer: Aetna of NY Commercial	$16.04
Rate for Payer: Aetna of NY Medicare	$10.54
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$9.17
Rate for Payer: Cash Price	$17.19
Rate for Payer: CDPHP Medicare	$8.48
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$18.34
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$18.34
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$18.34
Rate for Payer: EmblemHealth Medicaid	$18.34
Rate for Payer: EmblemHealth Medicare	$7.79
Rate for Payer: EmblemHealth Select Care	$16.50
Rate for Payer: Fidelis Medicare	$9.17
Rate for Payer: Galaxy Health Commercial	$14.90
Rate for Payer: Hamaspik Choice Medicare	$9.17
Rate for Payer: Humana Medicare	$9.17
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$16.04
Rate for Payer: Local 1199SEIU Medicare	$10.54
Rate for Payer: MVP Health Care of NY Commercial	$17.19
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$12.90
Rate for Payer: MVP Health Care of NY Medicare	$9.63
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$3.44
Rate for Payer: United Healthcare Medicare	$9.17
Rate for Payer: WellCare Medicare	$12.61

TUBERCULIN PURIF PROT DERIV 5TU/0.1ML MD

Facility

$22.92

Service Code	NDC 42023010401
Hospital Charge Code	4400064
Hospital Revenue Code	250
Min. Negotiated Rate	$12.61
Max. Negotiated Rate	$14.90
Rate for Payer: Cash Price	$17.19
Rate for Payer: Galaxy Health Commercial	$14.90
Rate for Payer: WellCare Medicare	$12.61

TUBERCULIN PURIF PROT DERIV 5TU/0.1ML MD

Facility

$17.77

Service Code	NDC 42023010405
Hospital Charge Code	4400065
Hospital Revenue Code	250
Min. Negotiated Rate	$9.77
Max. Negotiated Rate	$11.55
Rate for Payer: Cash Price	$13.33
Rate for Payer: Galaxy Health Commercial	$11.55
Rate for Payer: WellCare Medicare	$9.77

TUBERCULIN PURIF PROT DERIV 5TU/0.1ML MD

Facility

$17.77

Service Code	NDC 42023010405
Hospital Charge Code	4400065
Hospital Revenue Code	250
Min. Negotiated Rate	$2.67
Max. Negotiated Rate	$14.22
Rate for Payer: Aetna of NY Commercial	$12.44
Rate for Payer: Aetna of NY Medicare	$8.17
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$7.11
Rate for Payer: Cash Price	$13.33
Rate for Payer: CDPHP Medicare	$6.57
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$14.22
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$14.22
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$14.22
Rate for Payer: EmblemHealth Medicaid	$14.22
Rate for Payer: EmblemHealth Medicare	$6.04
Rate for Payer: EmblemHealth Select Care	$12.79
Rate for Payer: Fidelis Medicare	$7.11
Rate for Payer: Galaxy Health Commercial	$11.55
Rate for Payer: Hamaspik Choice Medicare	$7.11
Rate for Payer: Humana Medicare	$7.11
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$12.44
Rate for Payer: Local 1199SEIU Medicare	$8.17
Rate for Payer: MVP Health Care of NY Commercial	$13.33
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$10.00
Rate for Payer: MVP Health Care of NY Medicare	$7.46
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$2.67
Rate for Payer: United Healthcare Medicare	$7.11
Rate for Payer: WellCare Medicare	$9.77

TUBING FLOWTRON

Facility

$46.35

Hospital Charge Code	4471654
Hospital Revenue Code	278
Min. Negotiated Rate	$6.95
Max. Negotiated Rate	$37.08
Rate for Payer: Aetna of NY Commercial	$32.45
Rate for Payer: Aetna of NY Medicare	$21.32
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$18.54
Rate for Payer: Cash Price	$34.76
Rate for Payer: CDPHP Medicare	$17.15
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$23.18
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$37.08
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$37.08
Rate for Payer: EmblemHealth Medicaid	$37.08
Rate for Payer: EmblemHealth Medicare	$15.76
Rate for Payer: EmblemHealth Select Care	$23.18
Rate for Payer: Fidelis Medicare	$18.54
Rate for Payer: Galaxy Health Commercial	$30.13
Rate for Payer: Hamaspik Choice Medicare	$18.54
Rate for Payer: Humana Medicare	$18.54
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$32.45
Rate for Payer: Local 1199SEIU Medicare	$21.32
Rate for Payer: MVP Health Care of NY Commercial	$30.13
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$30.13
Rate for Payer: MVP Health Care of NY Medicare	$19.47
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$6.95
Rate for Payer: United Healthcare Medicare	$18.54
Rate for Payer: WellCare Medicare	$25.49

TUBING FLOWTRON

Facility

$46.35

Hospital Charge Code	4471654
Hospital Revenue Code	278
Min. Negotiated Rate	$20.86
Max. Negotiated Rate	$32.45
Rate for Payer: Aetna of NY Commercial	$32.45
Rate for Payer: Cash Price	$34.76
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$23.18
Rate for Payer: EmblemHealth Select Care	$23.18
Rate for Payer: Galaxy Health Commercial	$30.13
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$32.45
Rate for Payer: Multiplan Commercial	$20.86
Rate for Payer: MVP Health Care of NY Commercial	$30.13
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$30.13
Rate for Payer: WellCare Medicare	$25.49

TUBING OXYGEN 7FT CRSH RESIS

Facility

$13.39

Hospital Charge Code	4472139
Hospital Revenue Code	270
Min. Negotiated Rate	$2.01
Max. Negotiated Rate	$10.71
Rate for Payer: Aetna of NY Commercial	$9.37
Rate for Payer: Aetna of NY Medicare	$6.16
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$5.36
Rate for Payer: Cash Price	$10.04
Rate for Payer: CDPHP Medicare	$4.95
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$10.71
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$10.71
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$10.71
Rate for Payer: EmblemHealth Medicaid	$10.71
Rate for Payer: EmblemHealth Medicare	$4.55
Rate for Payer: EmblemHealth Select Care	$9.64
Rate for Payer: Fidelis Medicare	$5.36
Rate for Payer: Galaxy Health Commercial	$8.70
Rate for Payer: Hamaspik Choice Medicare	$5.36
Rate for Payer: Humana Medicare	$5.36
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$9.37
Rate for Payer: Local 1199SEIU Medicare	$6.16
Rate for Payer: MVP Health Care of NY Commercial	$10.04
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$7.54
Rate for Payer: MVP Health Care of NY Medicare	$5.62
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$2.01
Rate for Payer: United Healthcare Medicare	$5.36
Rate for Payer: WellCare Medicare	$7.36

TUBING OXYGEN 7FT CRSH RESIS

Facility

$13.39

Hospital Charge Code	4472139
Hospital Revenue Code	270
Min. Negotiated Rate	$8.70
Max. Negotiated Rate	$8.70
Rate for Payer: Cash Price	$10.04
Rate for Payer: Galaxy Health Commercial	$8.70

TUMOR LOCALIZED SPECT

Facility

$154.00

Service Code	HCPCS 78803 26
Hospital Charge Code	5211235
Hospital Revenue Code	960
Min. Negotiated Rate	$23.10
Max. Negotiated Rate	$123.20
Rate for Payer: Aetna of NY Commercial	$107.80
Rate for Payer: Aetna of NY Medicare	$70.84
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$61.60
Rate for Payer: Cash Price	$115.50
Rate for Payer: CDPHP Medicare	$56.98
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$123.20
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$123.20
Rate for Payer: EmblemHealth Medicaid	$123.20
Rate for Payer: EmblemHealth Medicare	$52.36
Rate for Payer: Fidelis Medicare	$61.60
Rate for Payer: Galaxy Health Commercial	$100.10
Rate for Payer: Hamaspik Choice Medicare	$61.60
Rate for Payer: Humana Medicare	$61.60
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$107.80
Rate for Payer: Local 1199SEIU Medicare	$70.84
Rate for Payer: MVP Health Care of NY Commercial	$115.50
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$86.70
Rate for Payer: MVP Health Care of NY Medicare	$64.68
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$23.10
Rate for Payer: United Healthcare Medicare	$61.60
Rate for Payer: WellCare Medicare	$84.70

TUMOR LOCALIZED SPECT

Facility

$154.00

Service Code	HCPCS 78803 26
Hospital Charge Code	5211235
Hospital Revenue Code	960
Min. Negotiated Rate	$100.10
Max. Negotiated Rate	$100.10
Rate for Payer: Cash Price	$115.50
Rate for Payer: Galaxy Health Commercial	$100.10

TUMOR LOCALIZED SPECT

Facility

$4,063.00

Service Code	HCPCS 78803
Hospital Charge Code	4211235
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

TUMOR LOCALIZED SPECT

Facility

$4,063.00

Service Code	HCPCS 78803
Hospital Charge Code	4211235
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

TUNNELING TOOL

Facility

$1,007.34

Hospital Charge Code	4479096
Hospital Revenue Code	272
Min. Negotiated Rate	$654.77
Max. Negotiated Rate	$654.77
Rate for Payer: Cash Price	$755.50
Rate for Payer: Galaxy Health Commercial	$654.77

TUNNELING TOOL

Facility

$1,007.34

Hospital Charge Code	4479096
Hospital Revenue Code	272
Min. Negotiated Rate	$151.10
Max. Negotiated Rate	$805.87
Rate for Payer: Aetna of NY Commercial	$705.14
Rate for Payer: Aetna of NY Medicare	$463.38
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$402.94
Rate for Payer: Cash Price	$755.50
Rate for Payer: CDPHP Medicare	$372.72
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$805.87
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$805.87
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$805.87
Rate for Payer: EmblemHealth Medicaid	$805.87
Rate for Payer: EmblemHealth Medicare	$342.50
Rate for Payer: EmblemHealth Select Care	$725.28
Rate for Payer: Fidelis Medicare	$402.94
Rate for Payer: Galaxy Health Commercial	$654.77
Rate for Payer: Hamaspik Choice Medicare	$402.94
Rate for Payer: Humana Medicare	$402.94
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$705.14
Rate for Payer: Local 1199SEIU Medicare	$463.38
Rate for Payer: MVP Health Care of NY Commercial	$755.50
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$567.13
Rate for Payer: MVP Health Care of NY Medicare	$423.08
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$151.10
Rate for Payer: United Healthcare Medicare	$402.94
Rate for Payer: WellCare Medicare	$554.04

TX/PRO/DX INJ NEW DRUG ADDON

Facility

$150.00

Service Code	HCPCS 96375
Hospital Charge Code	4450108
Hospital Revenue Code	260
Min. Negotiated Rate	$97.50
Max. Negotiated Rate	$97.50
Rate for Payer: Cash Price	$112.50
Rate for Payer: Galaxy Health Commercial	$97.50

TX/PRO/DX INJ NEW DRUG ADDON

Facility

$150.00

Service Code	HCPCS 96375
Hospital Charge Code	4450108
Hospital Revenue Code	260
Min. Negotiated Rate	$22.50
Max. Negotiated Rate	$120.00
Rate for Payer: Aetna of NY Commercial	$105.00
Rate for Payer: Aetna of NY Medicare	$69.00
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$60.00
Rate for Payer: Cash Price	$112.50
Rate for Payer: CDPHP Medicare	$55.50
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$120.00
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$120.00
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$120.00
Rate for Payer: EmblemHealth Medicaid	$120.00
Rate for Payer: EmblemHealth Medicare	$51.00
Rate for Payer: EmblemHealth Select Care	$108.00
Rate for Payer: Fidelis Medicare	$60.00
Rate for Payer: Galaxy Health Commercial	$97.50
Rate for Payer: Hamaspik Choice Medicare	$60.00
Rate for Payer: Humana Medicare	$60.00
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$105.00
Rate for Payer: Local 1199SEIU Medicare	$69.00
Rate for Payer: MVP Health Care of NY Commercial	$112.50
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$84.45
Rate for Payer: MVP Health Care of NY Medicare	$63.00
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$112.50
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$22.50
Rate for Payer: United Healthcare Commercial	$112.50
Rate for Payer: United Healthcare Medicare	$60.00
Rate for Payer: WellCare Medicare	$82.50

Know your out-of-pocket cost for care.

All Charges