Ellenville Regional Hospital

All Charges

Charge

Type

Setting

Price

ARTHROCENTESIS ASPIR&/INJ MAJOR JT/BURSA W/US

Facility

$941.00

Service Code	HCPCS 20611
Hospital Charge Code	4201090
Hospital Revenue Code	402
Min. Negotiated Rate	$611.65
Max. Negotiated Rate	$611.65
Rate for Payer: Cash Price	$705.75
Rate for Payer: Galaxy Health Commercial	$611.65

ARTHROCENTESIS ASPIR&/INJ MAJOR JT/BURSA W/US

Facility

$187.00

Service Code	HCPCS 20611 26
Hospital Charge Code	5201090
Hospital Revenue Code	960
Min. Negotiated Rate	$28.05
Max. Negotiated Rate	$149.60
Rate for Payer: Aetna of NY Commercial	$130.90
Rate for Payer: Aetna of NY Medicare	$86.02
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$74.80
Rate for Payer: Cash Price	$140.25
Rate for Payer: CDPHP Medicare	$69.19
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$149.60
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$149.60
Rate for Payer: EmblemHealth Medicaid	$149.60
Rate for Payer: EmblemHealth Medicare	$63.58
Rate for Payer: Fidelis Medicare	$74.80
Rate for Payer: Galaxy Health Commercial	$121.55
Rate for Payer: Hamaspik Choice Medicare	$74.80
Rate for Payer: Humana Medicare	$74.80
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$130.90
Rate for Payer: Local 1199SEIU Medicare	$86.02
Rate for Payer: MVP Health Care of NY Commercial	$140.25
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$105.28
Rate for Payer: MVP Health Care of NY Medicare	$78.54
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$28.05
Rate for Payer: United Healthcare Medicare	$74.80
Rate for Payer: WellCare Medicare	$102.85

ARTHRODESIS; SUBTALAR

Facility

$12,539.82

Service Code	CPT 28725
Hospital Revenue Code	490
Min. Negotiated Rate	$1,900.00
Max. Negotiated Rate	$12,539.82
Rate for Payer: Aetna of NY Commercial	$1,900.00
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$1,900.00
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$2,373.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$12,539.82
Rate for Payer: United Healthcare Commercial	$2,373.00

ARTHROSCOPY, ANKLE (TIBIOTALAR AND FIBULOTALAR JOINTS), SURGICAL; DEBRIDEMENT, EXTENSIVE

Facility

$3,084.03

Service Code	CPT 29898
Hospital Revenue Code	490
Min. Negotiated Rate	$1,900.00
Max. Negotiated Rate	$3,084.03
Rate for Payer: Aetna of NY Commercial	$1,900.00
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$1,900.00
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$2,097.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$3,084.03
Rate for Payer: United Healthcare Commercial	$2,097.00

ARTHROSCOPY, ANKLE (TIBIOTALAR AND FIBULOTALAR JOINTS), SURGICAL; DEBRIDEMENT, LIMITED

Facility

$3,084.03

Service Code	CPT 29897
Hospital Revenue Code	490
Min. Negotiated Rate	$1,900.00
Max. Negotiated Rate	$3,084.03
Rate for Payer: Aetna of NY Commercial	$1,900.00
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$1,900.00
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$2,097.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$3,084.03
Rate for Payer: United Healthcare Commercial	$2,097.00

ARTHROSCOPY, ANKLE (TIBIOTALAR AND FIBULOTALAR JOINTS), SURGICAL; SYNOVECTOMY, PARTIAL

Facility

$3,084.03

Service Code	CPT 29895
Hospital Revenue Code	490
Min. Negotiated Rate	$1,900.00
Max. Negotiated Rate	$3,084.03
Rate for Payer: Aetna of NY Commercial	$1,900.00
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$1,900.00
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$2,097.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$3,084.03
Rate for Payer: United Healthcare Commercial	$2,097.00

ARTHROSCOPY, KNEE, SURGICAL; ABRASION ARTHROPLASTY (INCLUDES CHONDROPLASTY WHERE NECESSARY) OR MULTIPLE DRILLING OR MICROFRACTURE

Facility

$3,084.03

Service Code	CPT 29879
Hospital Revenue Code	490
Min. Negotiated Rate	$1,900.00
Max. Negotiated Rate	$3,084.03
Rate for Payer: Aetna of NY Commercial	$1,900.00
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$1,900.00
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$2,097.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$3,084.03
Rate for Payer: United Healthcare Commercial	$2,097.00

ARTHROSCOPY, KNEE, SURGICAL; SYNOVECTOMY, MAJOR, 2 OR MORE COMPARTMENTS (EG, MEDIAL OR LATERAL)

Facility

$3,084.03

Service Code	CPT 29876
Hospital Revenue Code	490
Min. Negotiated Rate	$1,900.00
Max. Negotiated Rate	$3,084.03
Rate for Payer: Aetna of NY Commercial	$1,900.00
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$1,900.00
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$2,097.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$3,084.03
Rate for Payer: United Healthcare Commercial	$2,097.00

ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCECTOMY (MEDIAL AND LATERAL, INCLUDING ANY MENISCAL SHAVING) INCLUDING DEBRIDEMENT/SHAVING OF ARTICULAR CARTILAGE (CHONDROPLASTY), SAME OR SEPARATE COMPARTMENT(S), WHEN PERFORMED

Facility

$3,084.03

Service Code	CPT 29880
Hospital Revenue Code	490
Min. Negotiated Rate	$1,900.00
Max. Negotiated Rate	$3,084.03
Rate for Payer: Aetna of NY Commercial	$1,900.00
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$1,900.00
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$2,097.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$3,084.03
Rate for Payer: United Healthcare Commercial	$2,097.00

ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCECTOMY (MEDIAL OR LATERAL, INCLUDING ANY MENISCAL SHAVING) INCLUDING DEBRIDEMENT/SHAVING OF ARTICULAR CARTILAGE (CHONDROPLASTY), SAME OR SEPARATE COMPARTMENT(S), WHEN PERFORMED

Facility

$3,084.03

Service Code	CPT 29881
Hospital Revenue Code	490
Min. Negotiated Rate	$1,900.00
Max. Negotiated Rate	$3,084.03
Rate for Payer: Aetna of NY Commercial	$1,900.00
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$1,900.00
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$2,097.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$3,084.03
Rate for Payer: United Healthcare Commercial	$2,097.00

ARTHROSCOPY PUMP TUBING

Facility

$179.22

Hospital Charge Code	4471297
Hospital Revenue Code	270
Min. Negotiated Rate	$116.49
Max. Negotiated Rate	$116.49
Rate for Payer: Cash Price	$134.42
Rate for Payer: Galaxy Health Commercial	$116.49

ARTHROSCOPY PUMP TUBING

Facility

$179.22

Hospital Charge Code	4471297
Hospital Revenue Code	270
Min. Negotiated Rate	$26.88
Max. Negotiated Rate	$143.38
Rate for Payer: Aetna of NY Commercial	$125.45
Rate for Payer: Aetna of NY Medicare	$82.44
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$71.69
Rate for Payer: Cash Price	$134.42
Rate for Payer: CDPHP Medicare	$66.31
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$143.38
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$143.38
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$143.38
Rate for Payer: EmblemHealth Medicaid	$143.38
Rate for Payer: EmblemHealth Medicare	$60.93
Rate for Payer: EmblemHealth Select Care	$129.04
Rate for Payer: Fidelis Medicare	$71.69
Rate for Payer: Galaxy Health Commercial	$116.49
Rate for Payer: Hamaspik Choice Medicare	$71.69
Rate for Payer: Humana Medicare	$71.69
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$125.45
Rate for Payer: Local 1199SEIU Medicare	$82.44
Rate for Payer: MVP Health Care of NY Commercial	$134.41
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$100.90
Rate for Payer: MVP Health Care of NY Medicare	$75.27
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$26.88
Rate for Payer: United Healthcare Medicare	$71.69
Rate for Payer: WellCare Medicare	$98.57

ARTIFICIAL TEARS 0.014 DROP 15 ML

Facility

$15.00

Service Code	NDC 536108494
Hospital Charge Code	4400073
Hospital Revenue Code	250
Min. Negotiated Rate	$8.25
Max. Negotiated Rate	$9.75
Rate for Payer: Cash Price	$11.25
Rate for Payer: Galaxy Health Commercial	$9.75
Rate for Payer: WellCare Medicare	$8.25

ARTIFICIAL TEARS 0.014 DROP 15 ML

Facility

$15.00

Service Code	NDC 536108494
Hospital Charge Code	4400073
Hospital Revenue Code	250
Min. Negotiated Rate	$2.25
Max. Negotiated Rate	$12.00
Rate for Payer: Aetna of NY Commercial	$10.50
Rate for Payer: Aetna of NY Medicare	$6.90
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$6.00
Rate for Payer: Cash Price	$11.25
Rate for Payer: CDPHP Medicare	$5.55
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$12.00
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$12.00
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$12.00
Rate for Payer: EmblemHealth Medicaid	$12.00
Rate for Payer: EmblemHealth Medicare	$5.10
Rate for Payer: EmblemHealth Select Care	$10.80
Rate for Payer: Fidelis Medicare	$6.00
Rate for Payer: Galaxy Health Commercial	$9.75
Rate for Payer: Hamaspik Choice Medicare	$6.00
Rate for Payer: Humana Medicare	$6.00
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$10.50
Rate for Payer: Local 1199SEIU Medicare	$6.90
Rate for Payer: MVP Health Care of NY Commercial	$11.25
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$8.45
Rate for Payer: MVP Health Care of NY Medicare	$6.30
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$2.25
Rate for Payer: United Healthcare Medicare	$6.00
Rate for Payer: WellCare Medicare	$8.25

ASCORBIC ACID (VITA C) 500MG TABS 100 EA

Facility

$6.18

Service Code	NDC 904052361
Hospital Charge Code	4400804
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

ASCORBIC ACID (VITA C) 500MG TABS 100 EA

Facility

$6.18

Service Code	NDC 904052361
Hospital Charge Code	4400804
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

ASPIRATE/INJ GANGLION CYST

Facility

$941.00

Service Code	HCPCS 20612
Hospital Charge Code	4856665
Hospital Revenue Code	761
Min. Negotiated Rate	$141.15
Max. Negotiated Rate	$752.80
Rate for Payer: Aetna of NY Commercial	$658.70
Rate for Payer: Aetna of NY Medicare	$432.86
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$376.40
Rate for Payer: Cash Price	$705.75
Rate for Payer: CDPHP Medicare	$348.17
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$752.80
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$752.80
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$752.80
Rate for Payer: EmblemHealth Medicaid	$752.80
Rate for Payer: EmblemHealth Medicare	$319.94
Rate for Payer: EmblemHealth Select Care	$677.52
Rate for Payer: Fidelis Medicare	$376.40
Rate for Payer: Galaxy Health Commercial	$611.65
Rate for Payer: Hamaspik Choice Medicare	$376.40
Rate for Payer: Humana Medicare	$376.40
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$658.70
Rate for Payer: Local 1199SEIU Medicare	$432.86
Rate for Payer: MVP Health Care of NY Commercial	$705.75
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$529.78
Rate for Payer: MVP Health Care of NY Medicare	$395.22
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$141.15
Rate for Payer: United Healthcare Medicare	$376.40
Rate for Payer: WellCare Medicare	$517.55

ASPIRATE/INJ GANGLION CYST

Facility

$941.00

Service Code	HCPCS 20612
Hospital Charge Code	4856665
Hospital Revenue Code	761
Min. Negotiated Rate	$611.65
Max. Negotiated Rate	$611.65
Rate for Payer: Cash Price	$705.75
Rate for Payer: Galaxy Health Commercial	$611.65

ASPIRATION BLADDER INSERT SUPRAPUBIC CATHETER

Facility

$6,407.00

Service Code	HCPCS 51102
Hospital Charge Code	4002001
Hospital Revenue Code	490
Min. Negotiated Rate	$4,164.55
Max. Negotiated Rate	$4,164.55
Rate for Payer: Cash Price	$4,805.25
Rate for Payer: Galaxy Health Commercial	$4,164.55

ASPIRATION BLADDER INSERT SUPRAPUBIC CATHETER

Facility

$6,407.00

Service Code	HCPCS 51102
Hospital Charge Code	4002001
Hospital Revenue Code	490
Min. Negotiated Rate	$961.05
Max. Negotiated Rate	$5,125.60
Rate for Payer: Aetna of NY Commercial	$1,900.00
Rate for Payer: Aetna of NY Medicare	$2,947.22
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$2,562.80
Rate for Payer: Cash Price	$4,805.25
Rate for Payer: Cash Price	$4,805.25
Rate for Payer: CDPHP Medicare	$2,370.59
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$5,125.60
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$5,125.60
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$5,125.60
Rate for Payer: EmblemHealth Medicaid	$5,125.60
Rate for Payer: EmblemHealth Medicare	$2,178.38
Rate for Payer: EmblemHealth Select Care	$4,613.04
Rate for Payer: Fidelis Medicare	$2,562.80
Rate for Payer: Galaxy Health Commercial	$4,164.55
Rate for Payer: Hamaspik Choice Medicare	$2,562.80
Rate for Payer: Humana Medicare	$2,562.80
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$1,900.00
Rate for Payer: Local 1199SEIU Medicare	$2,947.22
Rate for Payer: Multiplan Commercial	$5,125.60
Rate for Payer: MVP Health Care of NY Commercial	$4,805.25
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$3,607.14
Rate for Payer: MVP Health Care of NY Medicare	$2,690.94
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$2,097.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$961.05
Rate for Payer: United Healthcare Commercial	$2,097.00
Rate for Payer: United Healthcare Medicare	$2,562.80
Rate for Payer: WellCare Medicare	$3,523.85

ASPIRIN 325 MG film coated

Facility

$6.18

Service Code	NDC 66553000101
Hospital Charge Code	4401260
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

ASPIRIN 325 MG film coated

Facility

$6.18

Service Code	NDC 66553000101
Hospital Charge Code	4401260
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

ASPIRIN 325MG TABS 100 EA

Facility

$6.18

Service Code	NDC 63739052301
Hospital Charge Code	4400075
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

ASPIRIN 325MG TABS 100 EA

Facility

$6.18

Service Code	NDC 63739052301
Hospital Charge Code	4400075
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

ASPIRIN 81MG CHEW 25X30EA

Facility

$6.18

Service Code	NDC 66553000201
Hospital Charge Code	4400077
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

Know your out-of-pocket cost for care.

All Charges