Ellenville Regional Hospital

All Charges

Charge

Type

Setting

Price

18G X 100 RADIOFREQUENCY CANNULA

Facility

$25.75

Hospital Charge Code	4473033
Hospital Revenue Code	272
Min. Negotiated Rate	$16.74
Max. Negotiated Rate	$16.74
Rate for Payer: Cash Price	$19.31
Rate for Payer: Galaxy Health Commercial	$16.74

18" QUICK-FIT BASIC KNEE SPLIN

Facility

$52.53

Hospital Charge Code	4471599
Hospital Revenue Code	270
Min. Negotiated Rate	$34.14
Max. Negotiated Rate	$34.14
Rate for Payer: Cash Price	$39.40
Rate for Payer: Galaxy Health Commercial	$34.14

18" QUICK-FIT BASIC KNEE SPLIN

Facility

$52.53

Hospital Charge Code	4471599
Hospital Revenue Code	270
Min. Negotiated Rate	$7.88
Max. Negotiated Rate	$42.02
Rate for Payer: Aetna of NY Commercial	$36.77
Rate for Payer: Aetna of NY Medicare	$24.16
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$21.01
Rate for Payer: Cash Price	$39.40
Rate for Payer: CDPHP Medicare	$19.44
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$42.02
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$42.02
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$42.02
Rate for Payer: EmblemHealth Medicaid	$42.02
Rate for Payer: EmblemHealth Medicare	$17.86
Rate for Payer: EmblemHealth Select Care	$37.82
Rate for Payer: Fidelis Medicare	$21.01
Rate for Payer: Galaxy Health Commercial	$34.14
Rate for Payer: Hamaspik Choice Medicare	$21.01
Rate for Payer: Humana Medicare	$21.01
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$36.77
Rate for Payer: Local 1199SEIU Medicare	$24.16
Rate for Payer: MVP Health Care of NY Commercial	$39.40
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$29.57
Rate for Payer: MVP Health Care of NY Medicare	$22.06
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$7.88
Rate for Payer: United Healthcare Medicare	$21.01
Rate for Payer: WellCare Medicare	$28.89

1 POLYSORB GS-24

Facility

$16.48

Hospital Charge Code	4478145
Hospital Revenue Code	270
Min. Negotiated Rate	$2.47
Max. Negotiated Rate	$13.18
Rate for Payer: Aetna of NY Commercial	$11.54
Rate for Payer: Aetna of NY Medicare	$7.58
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$6.59
Rate for Payer: Cash Price	$12.36
Rate for Payer: CDPHP Medicare	$6.10
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$13.18
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$13.18
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$13.18
Rate for Payer: EmblemHealth Medicaid	$13.18
Rate for Payer: EmblemHealth Medicare	$5.60
Rate for Payer: EmblemHealth Select Care	$11.87
Rate for Payer: Fidelis Medicare	$6.59
Rate for Payer: Galaxy Health Commercial	$10.71
Rate for Payer: Hamaspik Choice Medicare	$6.59
Rate for Payer: Humana Medicare	$6.59
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$11.54
Rate for Payer: Local 1199SEIU Medicare	$7.58
Rate for Payer: MVP Health Care of NY Commercial	$12.36
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$9.28
Rate for Payer: MVP Health Care of NY Medicare	$6.92
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$2.47
Rate for Payer: United Healthcare Medicare	$6.59
Rate for Payer: WellCare Medicare	$9.06

1 POLYSORB GS-24

Facility

$16.48

Hospital Charge Code	4478145
Hospital Revenue Code	270
Min. Negotiated Rate	$10.71
Max. Negotiated Rate	$10.71
Rate for Payer: Cash Price	$12.36
Rate for Payer: Galaxy Health Commercial	$10.71

2019-NCOV CORONAVIRUS, SARS-COV-2/2019-NCOV (COVID-19), ANY TECHNIQUE, MULTIPLE TYPES OR SUBTYPES (INCLUDES ALL TARGETS), NON-CDC

Facility

$154.00

Service Code	HCPCS U0002
Hospital Charge Code	4302020
Hospital Revenue Code	300
Min. Negotiated Rate	$23.10
Max. Negotiated Rate	$123.20
Rate for Payer: Aetna of NY Commercial	$100.10
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 CBP/EPO/PPO/HMO/Network Access	$92.40
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: EmblemHealth Select Care	$92.40
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	$100.10
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: Oxford Health Plans Freedom/Liberty/Metro	$115.50
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$23.10
Rate for Payer: United Healthcare Commercial	$115.50
Rate for Payer: United Healthcare Medicare	$61.60
Rate for Payer: WellCare Medicare	$84.70

2019-NCOV CORONAVIRUS, SARS-COV-2/2019-NCOV (COVID-19), ANY TECHNIQUE, MULTIPLE TYPES OR SUBTYPES (INCLUDES ALL TARGETS), NON-CDC

Facility

$154.00

Service Code	HCPCS U0002
Hospital Charge Code	4302020
Hospital Revenue Code	300
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

2-0 ETHIBOND CT-2 SUTURE

Facility

$19.57

Hospital Charge Code	4471823
Hospital Revenue Code	270
Min. Negotiated Rate	$2.94
Max. Negotiated Rate	$15.66
Rate for Payer: Aetna of NY Commercial	$13.70
Rate for Payer: Aetna of NY Medicare	$9.00
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$7.83
Rate for Payer: Cash Price	$14.68
Rate for Payer: CDPHP Medicare	$7.24
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$15.66
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$15.66
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$15.66
Rate for Payer: EmblemHealth Medicaid	$15.66
Rate for Payer: EmblemHealth Medicare	$6.65
Rate for Payer: EmblemHealth Select Care	$14.09
Rate for Payer: Fidelis Medicare	$7.83
Rate for Payer: Galaxy Health Commercial	$12.72
Rate for Payer: Hamaspik Choice Medicare	$7.83
Rate for Payer: Humana Medicare	$7.83
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$13.70
Rate for Payer: Local 1199SEIU Medicare	$9.00
Rate for Payer: MVP Health Care of NY Commercial	$14.68
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$11.02
Rate for Payer: MVP Health Care of NY Medicare	$8.22
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$2.94
Rate for Payer: United Healthcare Medicare	$7.83
Rate for Payer: WellCare Medicare	$10.76

2-0 ETHIBOND CT-2 SUTURE

Facility

$19.57

Hospital Charge Code	4471823
Hospital Revenue Code	270
Min. Negotiated Rate	$12.72
Max. Negotiated Rate	$12.72
Rate for Payer: Cash Price	$14.68
Rate for Payer: Galaxy Health Commercial	$12.72

2-0 ETHILON PS-2

Facility

$13.39

Hospital Charge Code	4478166
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

2-0 ETHILON PS-2

Facility

$13.39

Hospital Charge Code	4478166
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

20GA 1 1/4" GRIP HUBER NEEDLE

Facility

$15.45

Hospital Charge Code	4472091
Hospital Revenue Code	270
Min. Negotiated Rate	$2.32
Max. Negotiated Rate	$12.36
Rate for Payer: Aetna of NY Commercial	$10.81
Rate for Payer: Aetna of NY Medicare	$7.11
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$6.18
Rate for Payer: Cash Price	$11.59
Rate for Payer: CDPHP Medicare	$5.72
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$12.36
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$12.36
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$12.36
Rate for Payer: EmblemHealth Medicaid	$12.36
Rate for Payer: EmblemHealth Medicare	$5.25
Rate for Payer: EmblemHealth Select Care	$11.12
Rate for Payer: Fidelis Medicare	$6.18
Rate for Payer: Galaxy Health Commercial	$10.04
Rate for Payer: Hamaspik Choice Medicare	$6.18
Rate for Payer: Humana Medicare	$6.18
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$10.81
Rate for Payer: Local 1199SEIU Medicare	$7.11
Rate for Payer: MVP Health Care of NY Commercial	$11.59
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$8.70
Rate for Payer: MVP Health Care of NY Medicare	$6.49
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$2.32
Rate for Payer: United Healthcare Medicare	$6.18
Rate for Payer: WellCare Medicare	$8.50

20GA 1 1/4" GRIP HUBER NEEDLE

Facility

$15.45

Hospital Charge Code	4472091
Hospital Revenue Code	270
Min. Negotiated Rate	$10.04
Max. Negotiated Rate	$10.04
Rate for Payer: Cash Price	$11.59
Rate for Payer: Galaxy Health Commercial	$10.04

20GA 1" GRIPPER HUBER NEEDLE

Facility

$15.45

Hospital Charge Code	4472090
Hospital Revenue Code	270
Min. Negotiated Rate	$10.04
Max. Negotiated Rate	$10.04
Rate for Payer: Cash Price	$11.59
Rate for Payer: Galaxy Health Commercial	$10.04

20GA 1" GRIPPER HUBER NEEDLE

Facility

$15.45

Hospital Charge Code	4472090
Hospital Revenue Code	270
Min. Negotiated Rate	$2.32
Max. Negotiated Rate	$12.36
Rate for Payer: Aetna of NY Commercial	$10.81
Rate for Payer: Aetna of NY Medicare	$7.11
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$6.18
Rate for Payer: Cash Price	$11.59
Rate for Payer: CDPHP Medicare	$5.72
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$12.36
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$12.36
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$12.36
Rate for Payer: EmblemHealth Medicaid	$12.36
Rate for Payer: EmblemHealth Medicare	$5.25
Rate for Payer: EmblemHealth Select Care	$11.12
Rate for Payer: Fidelis Medicare	$6.18
Rate for Payer: Galaxy Health Commercial	$10.04
Rate for Payer: Hamaspik Choice Medicare	$6.18
Rate for Payer: Humana Medicare	$6.18
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$10.81
Rate for Payer: Local 1199SEIU Medicare	$7.11
Rate for Payer: MVP Health Care of NY Commercial	$11.59
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$8.70
Rate for Payer: MVP Health Care of NY Medicare	$6.49
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$2.32
Rate for Payer: United Healthcare Medicare	$6.18
Rate for Payer: WellCare Medicare	$8.50

20GA 3/4" GRIPPER HUBER NEEDLE

Facility

$15.45

Hospital Charge Code	4472089
Hospital Revenue Code	270
Min. Negotiated Rate	$2.32
Max. Negotiated Rate	$12.36
Rate for Payer: Aetna of NY Commercial	$10.81
Rate for Payer: Aetna of NY Medicare	$7.11
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$6.18
Rate for Payer: Cash Price	$11.59
Rate for Payer: CDPHP Medicare	$5.72
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$12.36
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$12.36
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$12.36
Rate for Payer: EmblemHealth Medicaid	$12.36
Rate for Payer: EmblemHealth Medicare	$5.25
Rate for Payer: EmblemHealth Select Care	$11.12
Rate for Payer: Fidelis Medicare	$6.18
Rate for Payer: Galaxy Health Commercial	$10.04
Rate for Payer: Hamaspik Choice Medicare	$6.18
Rate for Payer: Humana Medicare	$6.18
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$10.81
Rate for Payer: Local 1199SEIU Medicare	$7.11
Rate for Payer: MVP Health Care of NY Commercial	$11.59
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$8.70
Rate for Payer: MVP Health Care of NY Medicare	$6.49
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$2.32
Rate for Payer: United Healthcare Medicare	$6.18
Rate for Payer: WellCare Medicare	$8.50

20GA 3/4" GRIPPER HUBER NEEDLE

Facility

$15.45

Hospital Charge Code	4472089
Hospital Revenue Code	270
Min. Negotiated Rate	$10.04
Max. Negotiated Rate	$10.04
Rate for Payer: Cash Price	$11.59
Rate for Payer: Galaxy Health Commercial	$10.04

20G X 100 RADIOFREQUENCY CANNULA

Facility

$25.75

Hospital Charge Code	4473034
Hospital Revenue Code	272
Min. Negotiated Rate	$3.86
Max. Negotiated Rate	$20.60
Rate for Payer: Aetna of NY Commercial	$18.02
Rate for Payer: Aetna of NY Medicare	$11.85
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$10.30
Rate for Payer: Cash Price	$19.31
Rate for Payer: CDPHP Medicare	$9.53
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$20.60
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$20.60
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$20.60
Rate for Payer: EmblemHealth Medicaid	$20.60
Rate for Payer: EmblemHealth Medicare	$8.76
Rate for Payer: EmblemHealth Select Care	$18.54
Rate for Payer: Fidelis Medicare	$10.30
Rate for Payer: Galaxy Health Commercial	$16.74
Rate for Payer: Hamaspik Choice Medicare	$10.30
Rate for Payer: Humana Medicare	$10.30
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$18.02
Rate for Payer: Local 1199SEIU Medicare	$11.85
Rate for Payer: MVP Health Care of NY Commercial	$19.31
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$14.50
Rate for Payer: MVP Health Care of NY Medicare	$10.81
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$3.86
Rate for Payer: United Healthcare Medicare	$10.30
Rate for Payer: WellCare Medicare	$14.16

20G X 100 RADIOFREQUENCY CANNULA

Facility

$25.75

Hospital Charge Code	4473034
Hospital Revenue Code	272
Min. Negotiated Rate	$16.74
Max. Negotiated Rate	$16.74
Rate for Payer: Cash Price	$19.31
Rate for Payer: Galaxy Health Commercial	$16.74

20MEQ KCL IN5% DEXTROSE+.9%SODCHL 1000ML

Facility

$10.30

Service Code	NDC 409710709
Hospital Charge Code	4450027
Hospital Revenue Code	258
Min. Negotiated Rate	$1.54
Max. Negotiated Rate	$8.24
Rate for Payer: Aetna of NY Commercial	$7.21
Rate for Payer: Aetna of NY Medicare	$4.74
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$4.12
Rate for Payer: Cash Price	$7.72
Rate for Payer: CDPHP Medicare	$3.81
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$8.24
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$8.24
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$8.24
Rate for Payer: EmblemHealth Medicaid	$8.24
Rate for Payer: EmblemHealth Medicare	$3.50
Rate for Payer: EmblemHealth Select Care	$7.42
Rate for Payer: Fidelis Medicare	$4.12
Rate for Payer: Galaxy Health Commercial	$6.70
Rate for Payer: Hamaspik Choice Medicare	$4.12
Rate for Payer: Humana Medicare	$4.12
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$7.21
Rate for Payer: Local 1199SEIU Medicare	$4.74
Rate for Payer: MVP Health Care of NY Commercial	$7.72
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$5.80
Rate for Payer: MVP Health Care of NY Medicare	$4.33
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$1.54
Rate for Payer: United Healthcare Medicare	$4.12
Rate for Payer: WellCare Medicare	$5.67

20MEQ KCL IN5% DEXTROSE+.9%SODCHL 1000ML

Facility

$10.30

Service Code	NDC 409710709
Hospital Charge Code	4450027
Hospital Revenue Code	258
Min. Negotiated Rate	$6.70
Max. Negotiated Rate	$6.70
Rate for Payer: Cash Price	$7.72
Rate for Payer: Galaxy Health Commercial	$6.70

20MEQ KCL INDEXTRO 5%+.45%SOD CHL 1000ML

Facility

$7.73

Service Code	NDC 409790209
Hospital Charge Code	4450028
Hospital Revenue Code	258
Min. Negotiated Rate	$1.16
Max. Negotiated Rate	$6.18
Rate for Payer: Aetna of NY Commercial	$5.41
Rate for Payer: Aetna of NY Medicare	$3.56
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$3.09
Rate for Payer: Cash Price	$5.80
Rate for Payer: CDPHP Medicare	$2.86
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$6.18
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$6.18
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$6.18
Rate for Payer: EmblemHealth Medicaid	$6.18
Rate for Payer: EmblemHealth Medicare	$2.63
Rate for Payer: EmblemHealth Select Care	$5.57
Rate for Payer: Fidelis Medicare	$3.09
Rate for Payer: Galaxy Health Commercial	$5.02
Rate for Payer: Hamaspik Choice Medicare	$3.09
Rate for Payer: Humana Medicare	$3.09
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$5.41
Rate for Payer: Local 1199SEIU Medicare	$3.56
Rate for Payer: MVP Health Care of NY Commercial	$5.80
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$4.35
Rate for Payer: MVP Health Care of NY Medicare	$3.25
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$1.16
Rate for Payer: United Healthcare Medicare	$3.09
Rate for Payer: WellCare Medicare	$4.25

20MEQ KCL INDEXTRO 5%+.45%SOD CHL 1000ML

Facility

$7.73

Service Code	NDC 409790209
Hospital Charge Code	4450028
Hospital Revenue Code	258
Min. Negotiated Rate	$5.02
Max. Negotiated Rate	$5.02
Rate for Payer: Cash Price	$5.80
Rate for Payer: Galaxy Health Commercial	$5.02

20 MEQ KCL IN DEXTROSE 5% 1000 ML

Facility

$9.27

Service Code	NDC 409790509
Hospital Charge Code	4450018
Hospital Revenue Code	258
Min. Negotiated Rate	$1.39
Max. Negotiated Rate	$7.42
Rate for Payer: Aetna of NY Commercial	$6.49
Rate for Payer: Aetna of NY Medicare	$4.26
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$3.71
Rate for Payer: Cash Price	$6.95
Rate for Payer: CDPHP Medicare	$3.43
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$7.42
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$7.42
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$7.42
Rate for Payer: EmblemHealth Medicaid	$7.42
Rate for Payer: EmblemHealth Medicare	$3.15
Rate for Payer: EmblemHealth Select Care	$6.67
Rate for Payer: Fidelis Medicare	$3.71
Rate for Payer: Galaxy Health Commercial	$6.03
Rate for Payer: Hamaspik Choice Medicare	$3.71
Rate for Payer: Humana Medicare	$3.71
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$6.49
Rate for Payer: Local 1199SEIU Medicare	$4.26
Rate for Payer: MVP Health Care of NY Commercial	$6.95
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$5.22
Rate for Payer: MVP Health Care of NY Medicare	$3.89
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$1.39
Rate for Payer: United Healthcare Medicare	$3.71
Rate for Payer: WellCare Medicare	$5.10

20 MEQ KCL IN DEXTROSE 5% 1000 ML

Facility

$9.27

Service Code	NDC 409790509
Hospital Charge Code	4450018
Hospital Revenue Code	258
Min. Negotiated Rate	$6.03
Max. Negotiated Rate	$6.03
Rate for Payer: Cash Price	$6.95
Rate for Payer: Galaxy Health Commercial	$6.03

Know your out-of-pocket cost for care.

All Charges