Ellenville Regional Hospital

All Charges

Charge

Type

Setting

Price

18G X 100 RADIOFREQUENCY CANNULA

Facility

$25.00

Hospital Charge Code	4473033
Hospital Revenue Code	272
Min. Negotiated Rate	$16.25
Max. Negotiated Rate	$16.25
Rate for Payer: Cash Price	$18.75
Rate for Payer: Galaxy Health Commercial	$16.25

18" QUICK-FIT BASIC KNEE SPLIN

Facility

$51.00

Hospital Charge Code	4471599
Hospital Revenue Code	270
Min. Negotiated Rate	$33.15
Max. Negotiated Rate	$33.15
Rate for Payer: Cash Price	$38.25
Rate for Payer: Galaxy Health Commercial	$33.15

18" QUICK-FIT BASIC KNEE SPLIN

Facility

$51.00

Hospital Charge Code	4471599
Hospital Revenue Code	270
Min. Negotiated Rate	$17.34
Max. Negotiated Rate	$41.06
Rate for Payer: Aetna of NY Commercial	$35.70
Rate for Payer: Aetna of NY Medicare	$23.46
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group	$38.25
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO	$38.25
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$18.87
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp	$25.50
Rate for Payer: Cash Price	$38.25
Rate for Payer: CDPHP Commercial	$41.06
Rate for Payer: CDPHP Medicare	$18.87
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$40.80
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$40.80
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$40.80
Rate for Payer: EmblemHealth Medicaid	$40.80
Rate for Payer: EmblemHealth Medicare	$17.34
Rate for Payer: EmblemHealth Select Care	$36.72
Rate for Payer: Fidelis Medicare	$19.44
Rate for Payer: Galaxy Health Commercial	$33.15
Rate for Payer: Hamaspik Choice Medicare	$18.87
Rate for Payer: Humana Medicare	$18.87
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$35.70
Rate for Payer: Local 1199SEIU Medicare	$23.46
Rate for Payer: MVP Health Care of NY Commercial	$38.25
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$28.71
Rate for Payer: MVP Health Care of NY Medicare	$19.81
Rate for Payer: United Healthcare Medicare	$18.87
Rate for Payer: WellCare Medicare	$28.05

1 POLYSORB GS-24

Facility

$16.00

Hospital Charge Code	4478145
Hospital Revenue Code	270
Min. Negotiated Rate	$10.40
Max. Negotiated Rate	$10.40
Rate for Payer: Cash Price	$12.00
Rate for Payer: Galaxy Health Commercial	$10.40

1 POLYSORB GS-24

Facility

$16.00

Hospital Charge Code	4478145
Hospital Revenue Code	270
Min. Negotiated Rate	$5.44
Max. Negotiated Rate	$12.88
Rate for Payer: Aetna of NY Commercial	$11.20
Rate for Payer: Aetna of NY Medicare	$7.36
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group	$12.00
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO	$12.00
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$5.92
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp	$8.00
Rate for Payer: Cash Price	$12.00
Rate for Payer: CDPHP Commercial	$12.88
Rate for Payer: CDPHP Medicare	$5.92
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$12.80
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$12.80
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$12.80
Rate for Payer: EmblemHealth Medicaid	$12.80
Rate for Payer: EmblemHealth Medicare	$5.44
Rate for Payer: EmblemHealth Select Care	$11.52
Rate for Payer: Fidelis Medicare	$6.10
Rate for Payer: Galaxy Health Commercial	$10.40
Rate for Payer: Hamaspik Choice Medicare	$5.92
Rate for Payer: Humana Medicare	$5.92
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$11.20
Rate for Payer: Local 1199SEIU Medicare	$7.36
Rate for Payer: MVP Health Care of NY Commercial	$12.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$9.01
Rate for Payer: MVP Health Care of NY Medicare	$6.22
Rate for Payer: United Healthcare Medicare	$5.92
Rate for Payer: WellCare Medicare	$8.80

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

Facility

$162.00

Service Code	HCPCS U0002
Hospital Charge Code	4302020
Hospital Revenue Code	300
Min. Negotiated Rate	$30.79
Max. Negotiated Rate	$130.41
Rate for Payer: Aetna of NY Commercial	$105.30
Rate for Payer: Aetna of NY Medicare	$74.52
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group	$121.50
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO	$121.50
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$59.94
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp	$81.00
Rate for Payer: Cash Price	$121.50
Rate for Payer: Cash Price	$121.50
Rate for Payer: CDPHP Commercial	$130.41
Rate for Payer: CDPHP Medicare	$59.94
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$97.20
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$129.60
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$129.60
Rate for Payer: EmblemHealth Medicaid	$129.60
Rate for Payer: EmblemHealth Medicare	$55.08
Rate for Payer: EmblemHealth Select Care	$97.20
Rate for Payer: Fidelis Medicare	$61.74
Rate for Payer: Galaxy Health Commercial	$105.30
Rate for Payer: Hamaspik Choice Medicare	$59.94
Rate for Payer: Humana Medicare	$59.94
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$105.30
Rate for Payer: Local 1199SEIU Medicare	$74.52
Rate for Payer: MVP Health Care of NY Commercial	$121.50
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$91.21
Rate for Payer: MVP Health Care of NY Medicare	$62.94
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$121.50
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$30.79
Rate for Payer: United Healthcare Commercial	$121.50
Rate for Payer: United Healthcare Medicare	$59.94
Rate for Payer: WellCare Medicare	$89.10

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

Facility

$162.00

Service Code	HCPCS U0002
Hospital Charge Code	4302020
Hospital Revenue Code	300
Min. Negotiated Rate	$105.30
Max. Negotiated Rate	$105.30
Rate for Payer: Cash Price	$121.50
Rate for Payer: Galaxy Health Commercial	$105.30

2-0 ETHIBOND CT-2 SUTURE

Facility

$19.00

Hospital Charge Code	4471823
Hospital Revenue Code	270
Min. Negotiated Rate	$12.35
Max. Negotiated Rate	$12.35
Rate for Payer: Cash Price	$14.25
Rate for Payer: Galaxy Health Commercial	$12.35

2-0 ETHIBOND CT-2 SUTURE

Facility

$19.00

Hospital Charge Code	4471823
Hospital Revenue Code	270
Min. Negotiated Rate	$6.46
Max. Negotiated Rate	$15.30
Rate for Payer: Aetna of NY Commercial	$13.30
Rate for Payer: Aetna of NY Medicare	$8.74
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group	$14.25
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO	$14.25
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$7.03
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp	$9.50
Rate for Payer: Cash Price	$14.25
Rate for Payer: CDPHP Commercial	$15.30
Rate for Payer: CDPHP Medicare	$7.03
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$15.20
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$15.20
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$15.20
Rate for Payer: EmblemHealth Medicaid	$15.20
Rate for Payer: EmblemHealth Medicare	$6.46
Rate for Payer: EmblemHealth Select Care	$13.68
Rate for Payer: Fidelis Medicare	$7.24
Rate for Payer: Galaxy Health Commercial	$12.35
Rate for Payer: Hamaspik Choice Medicare	$7.03
Rate for Payer: Humana Medicare	$7.03
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$13.30
Rate for Payer: Local 1199SEIU Medicare	$8.74
Rate for Payer: MVP Health Care of NY Commercial	$14.25
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$10.70
Rate for Payer: MVP Health Care of NY Medicare	$7.38
Rate for Payer: United Healthcare Medicare	$7.03
Rate for Payer: WellCare Medicare	$10.45

2-0 ETHILON PS-2

Facility

$13.00

Hospital Charge Code	4478166
Hospital Revenue Code	270
Min. Negotiated Rate	$4.42
Max. Negotiated Rate	$10.46
Rate for Payer: Aetna of NY Commercial	$9.10
Rate for Payer: Aetna of NY Medicare	$5.98
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group	$9.75
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO	$9.75
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$4.81
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp	$6.50
Rate for Payer: Cash Price	$9.75
Rate for Payer: CDPHP Commercial	$10.46
Rate for Payer: CDPHP Medicare	$4.81
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$10.40
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$10.40
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$10.40
Rate for Payer: EmblemHealth Medicaid	$10.40
Rate for Payer: EmblemHealth Medicare	$4.42
Rate for Payer: EmblemHealth Select Care	$9.36
Rate for Payer: Fidelis Medicare	$4.95
Rate for Payer: Galaxy Health Commercial	$8.45
Rate for Payer: Hamaspik Choice Medicare	$4.81
Rate for Payer: Humana Medicare	$4.81
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$9.10
Rate for Payer: Local 1199SEIU Medicare	$5.98
Rate for Payer: MVP Health Care of NY Commercial	$9.75
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$7.32
Rate for Payer: MVP Health Care of NY Medicare	$5.05
Rate for Payer: United Healthcare Medicare	$4.81
Rate for Payer: WellCare Medicare	$7.15

2-0 ETHILON PS-2

Facility

$13.00

Hospital Charge Code	4478166
Hospital Revenue Code	270
Min. Negotiated Rate	$8.45
Max. Negotiated Rate	$8.45
Rate for Payer: Cash Price	$9.75
Rate for Payer: Galaxy Health Commercial	$8.45

20GA 1 1/4" GRIP HUBER NEEDLE

Facility

$15.00

Hospital Charge Code	4472091
Hospital Revenue Code	270
Min. Negotiated Rate	$9.75
Max. Negotiated Rate	$9.75
Rate for Payer: Cash Price	$11.25
Rate for Payer: Galaxy Health Commercial	$9.75

20GA 1 1/4" GRIP HUBER NEEDLE

Facility

$15.00

Hospital Charge Code	4472091
Hospital Revenue Code	270
Min. Negotiated Rate	$5.10
Max. Negotiated Rate	$12.08
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) Blue Access/Small Group	$11.25
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO	$11.25
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$5.55
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp	$7.50
Rate for Payer: Cash Price	$11.25
Rate for Payer: CDPHP Commercial	$12.08
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	$5.72
Rate for Payer: Galaxy Health Commercial	$9.75
Rate for Payer: Hamaspik Choice Medicare	$5.55
Rate for Payer: Humana Medicare	$5.55
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	$8.44
Rate for Payer: MVP Health Care of NY Medicare	$5.83
Rate for Payer: United Healthcare Medicare	$5.55
Rate for Payer: WellCare Medicare	$8.25

20GA 1" GRIPPER HUBER NEEDLE

Facility

$15.00

Hospital Charge Code	4472090
Hospital Revenue Code	270
Min. Negotiated Rate	$9.75
Max. Negotiated Rate	$9.75
Rate for Payer: Cash Price	$11.25
Rate for Payer: Galaxy Health Commercial	$9.75

20GA 1" GRIPPER HUBER NEEDLE

Facility

$15.00

Hospital Charge Code	4472090
Hospital Revenue Code	270
Min. Negotiated Rate	$5.10
Max. Negotiated Rate	$12.08
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) Blue Access/Small Group	$11.25
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO	$11.25
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$5.55
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp	$7.50
Rate for Payer: Cash Price	$11.25
Rate for Payer: CDPHP Commercial	$12.08
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	$5.72
Rate for Payer: Galaxy Health Commercial	$9.75
Rate for Payer: Hamaspik Choice Medicare	$5.55
Rate for Payer: Humana Medicare	$5.55
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	$8.44
Rate for Payer: MVP Health Care of NY Medicare	$5.83
Rate for Payer: United Healthcare Medicare	$5.55
Rate for Payer: WellCare Medicare	$8.25

20GA 3/4" GRIPPER HUBER NEEDLE

Facility

$15.00

Hospital Charge Code	4472089
Hospital Revenue Code	270
Min. Negotiated Rate	$9.75
Max. Negotiated Rate	$9.75
Rate for Payer: Cash Price	$11.25
Rate for Payer: Galaxy Health Commercial	$9.75

20GA 3/4" GRIPPER HUBER NEEDLE

Facility

$15.00

Hospital Charge Code	4472089
Hospital Revenue Code	270
Min. Negotiated Rate	$5.10
Max. Negotiated Rate	$12.08
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) Blue Access/Small Group	$11.25
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO	$11.25
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$5.55
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp	$7.50
Rate for Payer: Cash Price	$11.25
Rate for Payer: CDPHP Commercial	$12.08
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	$5.72
Rate for Payer: Galaxy Health Commercial	$9.75
Rate for Payer: Hamaspik Choice Medicare	$5.55
Rate for Payer: Humana Medicare	$5.55
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	$8.44
Rate for Payer: MVP Health Care of NY Medicare	$5.83
Rate for Payer: United Healthcare Medicare	$5.55
Rate for Payer: WellCare Medicare	$8.25

20G X 100 RADIOFREQUENCY CANNULA

Facility

$25.00

Hospital Charge Code	4473034
Hospital Revenue Code	272
Min. Negotiated Rate	$8.50
Max. Negotiated Rate	$20.12
Rate for Payer: Aetna of NY Commercial	$17.50
Rate for Payer: Aetna of NY Medicare	$11.50
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group	$18.75
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO	$18.75
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$9.25
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp	$12.50
Rate for Payer: Cash Price	$18.75
Rate for Payer: CDPHP Commercial	$20.12
Rate for Payer: CDPHP Medicare	$9.25
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$20.00
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$20.00
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$20.00
Rate for Payer: EmblemHealth Medicaid	$20.00
Rate for Payer: EmblemHealth Medicare	$8.50
Rate for Payer: EmblemHealth Select Care	$18.00
Rate for Payer: Fidelis Medicare	$9.53
Rate for Payer: Galaxy Health Commercial	$16.25
Rate for Payer: Hamaspik Choice Medicare	$9.25
Rate for Payer: Humana Medicare	$9.25
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$17.50
Rate for Payer: Local 1199SEIU Medicare	$11.50
Rate for Payer: MVP Health Care of NY Commercial	$18.75
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$14.08
Rate for Payer: MVP Health Care of NY Medicare	$9.71
Rate for Payer: United Healthcare Medicare	$9.25
Rate for Payer: WellCare Medicare	$13.75

20G X 100 RADIOFREQUENCY CANNULA

Facility

$25.00

Hospital Charge Code	4473034
Hospital Revenue Code	272
Min. Negotiated Rate	$16.25
Max. Negotiated Rate	$16.25
Rate for Payer: Cash Price	$18.75
Rate for Payer: Galaxy Health Commercial	$16.25

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

Facility

$10.30

Service Code	NDC 00409710709
Hospital Charge Code	4450027
Hospital Revenue Code	258
Min. Negotiated Rate	$3.50
Max. Negotiated Rate	$8.29
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) Blue Access/Small Group	$7.72
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO	$7.72
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$3.81
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp	$5.15
Rate for Payer: Cash Price	$7.73
Rate for Payer: CDPHP Commercial	$8.29
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	$3.93
Rate for Payer: Galaxy Health Commercial	$6.70
Rate for Payer: Hamaspik Choice Medicare	$3.81
Rate for Payer: Humana Medicare	$3.81
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	$4.00
Rate for Payer: United Healthcare Medicare	$3.81
Rate for Payer: WellCare Medicare	$5.66

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

Facility

$10.30

Service Code	NDC 00409710709
Hospital Charge Code	4450027
Hospital Revenue Code	258
Min. Negotiated Rate	$6.70
Max. Negotiated Rate	$6.70
Rate for Payer: Cash Price	$7.73
Rate for Payer: Galaxy Health Commercial	$6.70

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

Facility

$7.73

Service Code	NDC 00409790209
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

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

Facility

$7.73

Service Code	NDC 00409790209
Hospital Charge Code	4450028
Hospital Revenue Code	258
Min. Negotiated Rate	$2.63
Max. Negotiated Rate	$6.22
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) Blue Access/Small Group	$5.80
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO	$5.80
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$2.86
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp	$3.86
Rate for Payer: Cash Price	$5.80
Rate for Payer: CDPHP Commercial	$6.22
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	$2.95
Rate for Payer: Galaxy Health Commercial	$5.02
Rate for Payer: Hamaspik Choice Medicare	$2.86
Rate for Payer: Humana Medicare	$2.86
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	$3.00
Rate for Payer: United Healthcare Medicare	$2.86
Rate for Payer: WellCare Medicare	$4.25

20 MEQ KCL IN DEXTROSE 5% 1000 ML

Facility

$9.27

Service Code	NDC 00409790509
Hospital Charge Code	4450018
Hospital Revenue Code	258
Min. Negotiated Rate	$3.15
Max. Negotiated Rate	$7.46
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) Blue Access/Small Group	$6.95
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO	$6.95
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$3.43
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp	$4.64
Rate for Payer: Cash Price	$6.95
Rate for Payer: CDPHP Commercial	$7.46
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	$3.53
Rate for Payer: Galaxy Health Commercial	$6.03
Rate for Payer: Hamaspik Choice Medicare	$3.43
Rate for Payer: Humana Medicare	$3.43
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	$3.60
Rate for Payer: United Healthcare Medicare	$3.43
Rate for Payer: WellCare Medicare	$5.10

20 MEQ KCL IN DEXTROSE 5% 1000 ML

Facility

$9.27

Service Code	NDC 00409790509
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