Ellenville Regional Hospital

All Charges

Charge

Type

Setting

Price

CAPTOPRIL RENAL

Facility

$172.00

Service Code	HCPCS 78708 26
Hospital Charge Code	5210034
Hospital Revenue Code	960
Min. Negotiated Rate	$25.80
Max. Negotiated Rate	$137.60
Rate for Payer: Aetna of NY Commercial	$120.40
Rate for Payer: Aetna of NY Medicare	$79.12
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$68.80
Rate for Payer: Cash Price	$129.00
Rate for Payer: CDPHP Medicare	$63.64
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$137.60
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$137.60
Rate for Payer: EmblemHealth Medicaid	$137.60
Rate for Payer: EmblemHealth Medicare	$58.48
Rate for Payer: Fidelis Medicare	$68.80
Rate for Payer: Galaxy Health Commercial	$111.80
Rate for Payer: Hamaspik Choice Medicare	$68.80
Rate for Payer: Humana Medicare	$68.80
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$120.40
Rate for Payer: Local 1199SEIU Medicare	$79.12
Rate for Payer: MVP Health Care of NY Commercial	$129.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$96.84
Rate for Payer: MVP Health Care of NY Medicare	$72.24
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$25.80
Rate for Payer: United Healthcare Medicare	$68.80
Rate for Payer: WellCare Medicare	$94.60

CAPTOPRIL RENAL

Facility

$1,664.00

Service Code	HCPCS 78708
Hospital Charge Code	4210034
Hospital Revenue Code	341
Min. Negotiated Rate	$1,081.60
Max. Negotiated Rate	$1,081.60
Rate for Payer: Cash Price	$1,248.00
Rate for Payer: Galaxy Health Commercial	$1,081.60

CAPTOPRIL RENAL

Facility

$172.00

Service Code	HCPCS 78708 26
Hospital Charge Code	5210034
Hospital Revenue Code	960
Min. Negotiated Rate	$111.80
Max. Negotiated Rate	$111.80
Rate for Payer: Cash Price	$129.00
Rate for Payer: Galaxy Health Commercial	$111.80

CAPTOPRIL RENAL

Facility

$1,664.00

Service Code	HCPCS 78708
Hospital Charge Code	4210034
Hospital Revenue Code	341
Min. Negotiated Rate	$249.60
Max. Negotiated Rate	$1,545.00
Rate for Payer: Aetna of NY Commercial	$1,164.80
Rate for Payer: Aetna of NY Medicare	$765.44
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$665.60
Rate for Payer: Cash Price	$1,248.00
Rate for Payer: Cash Price	$1,248.00
Rate for Payer: CDPHP Medicare	$615.68
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$1,164.80
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$1,331.20
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$1,331.20
Rate for Payer: EmblemHealth Medicaid	$1,331.20
Rate for Payer: EmblemHealth Medicare	$565.76
Rate for Payer: EmblemHealth Select Care	$1,081.60
Rate for Payer: Fidelis Medicare	$665.60
Rate for Payer: Galaxy Health Commercial	$1,081.60
Rate for Payer: Hamaspik Choice Medicare	$665.60
Rate for Payer: Humana Medicare	$665.60
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$1,164.80
Rate for Payer: Local 1199SEIU Medicare	$765.44
Rate for Payer: MVP Health Care of NY Commercial	$1,248.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$936.83
Rate for Payer: MVP Health Care of NY Medicare	$698.88
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$1,545.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$249.60
Rate for Payer: United Healthcare Commercial	$1,545.00
Rate for Payer: United Healthcare Medicare	$665.60
Rate for Payer: WellCare Medicare	$915.20

CARBAMAZEPINE 200MG TABS 10X10EA

Facility

$6.18

Service Code	NDC 904617261
Hospital Charge Code	4400131
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

CARBAMAZEPINE 200MG TABS 10X10EA

Facility

$6.18

Service Code	NDC 904617261
Hospital Charge Code	4400131
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

carBAMazepine ER 100 MG TABLET 100 mcg, 100 eaches

Facility

$6.00

Service Code	NDC 51672412301
Hospital Charge Code	4401940
Hospital Revenue Code	250
Min. Negotiated Rate	$3.30
Max. Negotiated Rate	$3.90
Rate for Payer: Cash Price	$4.50
Rate for Payer: Galaxy Health Commercial	$3.90
Rate for Payer: WellCare Medicare	$3.30

carBAMazepine ER 100 MG TABLET 100 mcg, 100 eaches

Facility

$6.00

Service Code	NDC 51672412301
Hospital Charge Code	4401940
Hospital Revenue Code	250
Min. Negotiated Rate	$0.90
Max. Negotiated Rate	$4.80
Rate for Payer: Aetna of NY Commercial	$4.20
Rate for Payer: Aetna of NY Medicare	$2.76
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$2.40
Rate for Payer: Cash Price	$4.50
Rate for Payer: CDPHP Medicare	$2.22
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$4.80
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$4.80
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$4.80
Rate for Payer: EmblemHealth Medicaid	$4.80
Rate for Payer: EmblemHealth Medicare	$2.04
Rate for Payer: EmblemHealth Select Care	$4.32
Rate for Payer: Fidelis Medicare	$2.40
Rate for Payer: Galaxy Health Commercial	$3.90
Rate for Payer: Hamaspik Choice Medicare	$2.40
Rate for Payer: Humana Medicare	$2.40
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$4.20
Rate for Payer: Local 1199SEIU Medicare	$2.76
Rate for Payer: MVP Health Care of NY Commercial	$4.50
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$3.38
Rate for Payer: MVP Health Care of NY Medicare	$2.52
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$0.90
Rate for Payer: United Healthcare Medicare	$2.40
Rate for Payer: WellCare Medicare	$3.30

carBAMazepine ER 400 MG TABLET 400 mg, 100 eaches

Facility

$12.00

Service Code	NDC 71930007412
Hospital Charge Code	4401935
Hospital Revenue Code	250
Min. Negotiated Rate	$6.60
Max. Negotiated Rate	$7.80
Rate for Payer: Cash Price	$9.00
Rate for Payer: Galaxy Health Commercial	$7.80
Rate for Payer: WellCare Medicare	$6.60

carBAMazepine ER 400 MG TABLET 400 mg, 100 eaches

Facility

$12.00

Service Code	NDC 71930007412
Hospital Charge Code	4401935
Hospital Revenue Code	250
Min. Negotiated Rate	$1.80
Max. Negotiated Rate	$9.60
Rate for Payer: Aetna of NY Commercial	$8.40
Rate for Payer: Aetna of NY Medicare	$5.52
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$4.80
Rate for Payer: Cash Price	$9.00
Rate for Payer: CDPHP Medicare	$4.44
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$9.60
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$9.60
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$9.60
Rate for Payer: EmblemHealth Medicaid	$9.60
Rate for Payer: EmblemHealth Medicare	$4.08
Rate for Payer: EmblemHealth Select Care	$8.64
Rate for Payer: Fidelis Medicare	$4.80
Rate for Payer: Galaxy Health Commercial	$7.80
Rate for Payer: Hamaspik Choice Medicare	$4.80
Rate for Payer: Humana Medicare	$4.80
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$8.40
Rate for Payer: Local 1199SEIU Medicare	$5.52
Rate for Payer: MVP Health Care of NY Commercial	$9.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$6.76
Rate for Payer: MVP Health Care of NY Medicare	$5.04
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$1.80
Rate for Payer: United Healthcare Medicare	$4.80
Rate for Payer: WellCare Medicare	$6.60

CARBAMIDE PEROXIDE 0.065 DROP 15 ML

Facility

$15.36

Service Code	NDC 42037010478
Hospital Charge Code	4400264
Hospital Revenue Code	250
Min. Negotiated Rate	$2.30
Max. Negotiated Rate	$12.29
Rate for Payer: Aetna of NY Commercial	$10.75
Rate for Payer: Aetna of NY Medicare	$7.07
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$6.14
Rate for Payer: Cash Price	$11.52
Rate for Payer: CDPHP Medicare	$5.68
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$12.29
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$12.29
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$12.29
Rate for Payer: EmblemHealth Medicaid	$12.29
Rate for Payer: EmblemHealth Medicare	$5.22
Rate for Payer: EmblemHealth Select Care	$11.06
Rate for Payer: Fidelis Medicare	$6.14
Rate for Payer: Galaxy Health Commercial	$9.98
Rate for Payer: Hamaspik Choice Medicare	$6.14
Rate for Payer: Humana Medicare	$6.14
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$10.75
Rate for Payer: Local 1199SEIU Medicare	$7.07
Rate for Payer: MVP Health Care of NY Commercial	$11.52
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$8.65
Rate for Payer: MVP Health Care of NY Medicare	$6.45
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$2.30
Rate for Payer: United Healthcare Medicare	$6.14
Rate for Payer: WellCare Medicare	$8.45

CARBAMIDE PEROXIDE 0.065 DROP 15 ML

Facility

$15.36

Service Code	NDC 42037010478
Hospital Charge Code	4400264
Hospital Revenue Code	250
Min. Negotiated Rate	$8.45
Max. Negotiated Rate	$9.98
Rate for Payer: Cash Price	$11.52
Rate for Payer: Galaxy Health Commercial	$9.98
Rate for Payer: WellCare Medicare	$8.45

CARBIDOPA/LEVODOPA 25-100MG TABS 10X10EA

Facility

$6.18

Service Code	NDC 904623761
Hospital Charge Code	4400132
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

CARBIDOPA/LEVODOPA 25-100MG TABS 10X10EA

Facility

$6.18

Service Code	NDC 904623761
Hospital Charge Code	4400132
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

CARBIDOPA-LEVODOPA 25-250 TAB 1 ea, 100 eaches

Facility

$6.00

Service Code	NDC 68084009411
Hospital Charge Code	4401433
Hospital Revenue Code	250
Min. Negotiated Rate	$0.90
Max. Negotiated Rate	$4.80
Rate for Payer: Aetna of NY Commercial	$4.20
Rate for Payer: Aetna of NY Medicare	$2.76
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$2.40
Rate for Payer: Cash Price	$4.50
Rate for Payer: CDPHP Medicare	$2.22
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$4.80
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$4.80
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$4.80
Rate for Payer: EmblemHealth Medicaid	$4.80
Rate for Payer: EmblemHealth Medicare	$2.04
Rate for Payer: EmblemHealth Select Care	$4.32
Rate for Payer: Fidelis Medicare	$2.40
Rate for Payer: Galaxy Health Commercial	$3.90
Rate for Payer: Hamaspik Choice Medicare	$2.40
Rate for Payer: Humana Medicare	$2.40
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$4.20
Rate for Payer: Local 1199SEIU Medicare	$2.76
Rate for Payer: MVP Health Care of NY Commercial	$4.50
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$3.38
Rate for Payer: MVP Health Care of NY Medicare	$2.52
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$0.90
Rate for Payer: United Healthcare Medicare	$2.40
Rate for Payer: WellCare Medicare	$3.30

CARBIDOPA-LEVODOPA 25-250 TAB 1 ea, 100 eaches

Facility

$6.00

Service Code	NDC 68084009411
Hospital Charge Code	4401433
Hospital Revenue Code	250
Min. Negotiated Rate	$3.30
Max. Negotiated Rate	$3.90
Rate for Payer: Cash Price	$4.50
Rate for Payer: Galaxy Health Commercial	$3.90
Rate for Payer: WellCare Medicare	$3.30

CARBIDOPA-LEVO ER 25-100 TAB 1 ea, 1 each

Facility

$6.00

Service Code	NDC 51079097801
Hospital Charge Code	4401432
Hospital Revenue Code	250
Min. Negotiated Rate	$0.90
Max. Negotiated Rate	$4.80
Rate for Payer: Aetna of NY Commercial	$4.20
Rate for Payer: Aetna of NY Medicare	$2.76
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$2.40
Rate for Payer: Cash Price	$4.50
Rate for Payer: CDPHP Medicare	$2.22
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$4.80
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$4.80
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$4.80
Rate for Payer: EmblemHealth Medicaid	$4.80
Rate for Payer: EmblemHealth Medicare	$2.04
Rate for Payer: EmblemHealth Select Care	$4.32
Rate for Payer: Fidelis Medicare	$2.40
Rate for Payer: Galaxy Health Commercial	$3.90
Rate for Payer: Hamaspik Choice Medicare	$2.40
Rate for Payer: Humana Medicare	$2.40
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$4.20
Rate for Payer: Local 1199SEIU Medicare	$2.76
Rate for Payer: MVP Health Care of NY Commercial	$4.50
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$3.38
Rate for Payer: MVP Health Care of NY Medicare	$2.52
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$0.90
Rate for Payer: United Healthcare Medicare	$2.40
Rate for Payer: WellCare Medicare	$3.30

CARBIDOPA-LEVO ER 25-100 TAB 1 ea, 1 each

Facility

$6.00

Service Code	NDC 51079097801
Hospital Charge Code	4401432
Hospital Revenue Code	250
Min. Negotiated Rate	$3.30
Max. Negotiated Rate	$3.90
Rate for Payer: Cash Price	$4.50
Rate for Payer: Galaxy Health Commercial	$3.90
Rate for Payer: WellCare Medicare	$3.30

CARBIDOPE/LEVODOPA EXTENDED RELEASE 25/1

Facility

$6.18

Service Code	NDC 68084028101
Hospital Charge Code	4409221
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

CARBIDOPE/LEVODOPA EXTENDED RELEASE 25/1

Facility

$6.18

Service Code	NDC 68084028101
Hospital Charge Code	4409221
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

CARBOGEN PER RX UNLSTD PULM PROCEDURE

Facility

$469.00

Service Code	HCPCS 94799
Hospital Charge Code	4530007
Hospital Revenue Code	460
Min. Negotiated Rate	$70.35
Max. Negotiated Rate	$375.20
Rate for Payer: Aetna of NY Commercial	$328.30
Rate for Payer: Aetna of NY Medicare	$215.74
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$187.60
Rate for Payer: Cash Price	$351.75
Rate for Payer: CDPHP Medicare	$173.53
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$328.30
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$375.20
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$375.20
Rate for Payer: EmblemHealth Medicaid	$375.20
Rate for Payer: EmblemHealth Medicare	$159.46
Rate for Payer: EmblemHealth Select Care	$304.85
Rate for Payer: Fidelis Medicare	$187.60
Rate for Payer: Galaxy Health Commercial	$304.85
Rate for Payer: Hamaspik Choice Medicare	$187.60
Rate for Payer: Humana Medicare	$187.60
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$328.30
Rate for Payer: Local 1199SEIU Medicare	$215.74
Rate for Payer: MVP Health Care of NY Commercial	$351.75
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$264.05
Rate for Payer: MVP Health Care of NY Medicare	$196.98
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$70.35
Rate for Payer: United Healthcare Medicare	$187.60
Rate for Payer: WellCare Medicare	$257.95

CARBOGEN PER RX UNLSTD PULM PROCEDURE

Facility

$469.00

Service Code	HCPCS 94799
Hospital Charge Code	4530007
Hospital Revenue Code	460
Min. Negotiated Rate	$304.85
Max. Negotiated Rate	$304.85
Rate for Payer: Cash Price	$351.75
Rate for Payer: Galaxy Health Commercial	$304.85

CARBON DIOXIDE (CO2)

Facility

$15.00

Service Code	HCPCS 82374
Hospital Charge Code	4300151
Hospital Revenue Code	301
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

CARBON DIOXIDE (CO2)

Facility

$15.00

Service Code	HCPCS 82374
Hospital Charge Code	4300151
Hospital Revenue Code	301
Min. Negotiated Rate	$2.25
Max. Negotiated Rate	$12.00
Rate for Payer: Aetna of NY Commercial	$9.75
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	$9.00
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	$9.00
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	$9.75
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: Oxford Health Plans Freedom/Liberty/Metro	$11.25
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$2.25
Rate for Payer: United Healthcare Commercial	$11.25
Rate for Payer: United Healthcare Medicare	$6.00
Rate for Payer: WellCare Medicare	$8.25

CARBOXYHEMOGLOBIN; QUANTITATIVE

Facility

$44.00

Service Code	HCPCS 82375
Hospital Charge Code	4302010
Hospital Revenue Code	300
Min. Negotiated Rate	$6.60
Max. Negotiated Rate	$35.20
Rate for Payer: Aetna of NY Commercial	$28.60
Rate for Payer: Aetna of NY Medicare	$20.24
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$17.60
Rate for Payer: Cash Price	$33.00
Rate for Payer: CDPHP Medicare	$16.28
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$26.40
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$35.20
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$35.20
Rate for Payer: EmblemHealth Medicaid	$35.20
Rate for Payer: EmblemHealth Medicare	$14.96
Rate for Payer: EmblemHealth Select Care	$26.40
Rate for Payer: Fidelis Medicare	$17.60
Rate for Payer: Galaxy Health Commercial	$28.60
Rate for Payer: Hamaspik Choice Medicare	$17.60
Rate for Payer: Humana Medicare	$17.60
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$28.60
Rate for Payer: Local 1199SEIU Medicare	$20.24
Rate for Payer: MVP Health Care of NY Commercial	$33.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$24.77
Rate for Payer: MVP Health Care of NY Medicare	$18.48
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$33.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$6.60
Rate for Payer: United Healthcare Commercial	$33.00
Rate for Payer: United Healthcare Medicare	$17.60
Rate for Payer: WellCare Medicare	$24.20

Know your out-of-pocket cost for care.

All Charges