Ellenville Regional Hospital

All Charges

Charge

Type

Setting

Price

CERVICOLL KIT CEK-17-75-2

Facility

$3,131.20

Hospital Charge Code	4479190
Hospital Revenue Code	270
Min. Negotiated Rate	$2,035.28
Max. Negotiated Rate	$2,035.28
Rate for Payer: Cash Price	$2,348.40
Rate for Payer: Galaxy Health Commercial	$2,035.28

CERVICOLL KIT CEK-17-75-2

Facility

$3,131.20

Hospital Charge Code	4479190
Hospital Revenue Code	270
Min. Negotiated Rate	$469.68
Max. Negotiated Rate	$2,504.96
Rate for Payer: Aetna of NY Commercial	$2,191.84
Rate for Payer: Aetna of NY Medicare	$1,440.35
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$1,252.48
Rate for Payer: Cash Price	$2,348.40
Rate for Payer: CDPHP Medicare	$1,158.54
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$2,504.96
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$2,504.96
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$2,504.96
Rate for Payer: EmblemHealth Medicaid	$2,504.96
Rate for Payer: EmblemHealth Medicare	$1,064.61
Rate for Payer: EmblemHealth Select Care	$2,254.46
Rate for Payer: Fidelis Medicare	$1,252.48
Rate for Payer: Galaxy Health Commercial	$2,035.28
Rate for Payer: Hamaspik Choice Medicare	$1,252.48
Rate for Payer: Humana Medicare	$1,252.48
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$2,191.84
Rate for Payer: Local 1199SEIU Medicare	$1,440.35
Rate for Payer: MVP Health Care of NY Commercial	$2,348.40
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$1,762.87
Rate for Payer: MVP Health Care of NY Medicare	$1,315.10
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$469.68
Rate for Payer: United Healthcare Medicare	$1,252.48
Rate for Payer: WellCare Medicare	$1,722.16

CHANGE CYSTOSTOMY TUBE COMPLICATED

Facility

$2,137.00

Service Code	HCPCS 51710
Hospital Charge Code	4002003
Hospital Revenue Code	490
Min. Negotiated Rate	$1,389.05
Max. Negotiated Rate	$1,389.05
Rate for Payer: Cash Price	$1,602.75
Rate for Payer: Galaxy Health Commercial	$1,389.05

CHANGE CYSTOSTOMY TUBE COMPLICATED

Facility

$2,137.00

Service Code	HCPCS 51710
Hospital Charge Code	4002003
Hospital Revenue Code	490
Min. Negotiated Rate	$320.55
Max. Negotiated Rate	$1,900.00
Rate for Payer: Aetna of NY Commercial	$1,900.00
Rate for Payer: Aetna of NY Medicare	$983.02
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$854.80
Rate for Payer: Cash Price	$1,602.75
Rate for Payer: Cash Price	$1,602.75
Rate for Payer: CDPHP Medicare	$790.69
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$1,709.60
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$1,709.60
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$1,709.60
Rate for Payer: EmblemHealth Medicaid	$1,709.60
Rate for Payer: EmblemHealth Medicare	$726.58
Rate for Payer: EmblemHealth Select Care	$1,538.64
Rate for Payer: Fidelis Medicare	$854.80
Rate for Payer: Galaxy Health Commercial	$1,389.05
Rate for Payer: Hamaspik Choice Medicare	$854.80
Rate for Payer: Humana Medicare	$854.80
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$1,900.00
Rate for Payer: Local 1199SEIU Medicare	$983.02
Rate for Payer: Multiplan Commercial	$1,709.60
Rate for Payer: MVP Health Care of NY Commercial	$1,602.75
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$1,203.13
Rate for Payer: MVP Health Care of NY Medicare	$897.54
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$1,828.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$320.55
Rate for Payer: United Healthcare Commercial	$1,828.00
Rate for Payer: United Healthcare Medicare	$854.80
Rate for Payer: WellCare Medicare	$1,175.35

CHANGE CYSTOSTOMY TUBE SIMPLE

Facility

$766.00

Service Code	HCPCS 51705
Hospital Charge Code	4002002
Hospital Revenue Code	490
Min. Negotiated Rate	$497.90
Max. Negotiated Rate	$497.90
Rate for Payer: Cash Price	$574.50
Rate for Payer: Galaxy Health Commercial	$497.90

CHANGE CYSTOSTOMY TUBE SIMPLE

Facility

$766.00

Service Code	HCPCS 51705
Hospital Charge Code	4002002
Hospital Revenue Code	490
Min. Negotiated Rate	$114.90
Max. Negotiated Rate	$1,900.00
Rate for Payer: Aetna of NY Commercial	$1,900.00
Rate for Payer: Aetna of NY Medicare	$352.36
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$306.40
Rate for Payer: Cash Price	$574.50
Rate for Payer: Cash Price	$574.50
Rate for Payer: CDPHP Medicare	$283.42
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$612.80
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$612.80
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$612.80
Rate for Payer: EmblemHealth Medicaid	$612.80
Rate for Payer: EmblemHealth Medicare	$260.44
Rate for Payer: EmblemHealth Select Care	$551.52
Rate for Payer: Fidelis Medicare	$306.40
Rate for Payer: Galaxy Health Commercial	$497.90
Rate for Payer: Hamaspik Choice Medicare	$306.40
Rate for Payer: Humana Medicare	$306.40
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$1,900.00
Rate for Payer: Local 1199SEIU Medicare	$352.36
Rate for Payer: Multiplan Commercial	$612.80
Rate for Payer: MVP Health Care of NY Commercial	$574.50
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$431.26
Rate for Payer: MVP Health Care of NY Medicare	$321.72
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$1,828.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$114.90
Rate for Payer: United Healthcare Commercial	$1,828.00
Rate for Payer: United Healthcare Medicare	$306.40
Rate for Payer: WellCare Medicare	$421.30

CHANGE OF CYSTOSTOMY TUBE; SIMPLE

Facility

$766.00

Service Code	HCPCS 51705
Hospital Charge Code	4602000
Hospital Revenue Code	450
Min. Negotiated Rate	$497.90
Max. Negotiated Rate	$497.90
Rate for Payer: Cash Price	$574.50
Rate for Payer: Galaxy Health Commercial	$497.90

CHANGE OF CYSTOSTOMY TUBE; SIMPLE

Facility

$766.00

Service Code	HCPCS 51705
Hospital Charge Code	4602000
Hospital Revenue Code	450
Min. Negotiated Rate	$114.90
Max. Negotiated Rate	$1,234.00
Rate for Payer: Aetna of NY Commercial	$1,000.00
Rate for Payer: Aetna of NY Medicare	$352.36
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$306.40
Rate for Payer: Cash Price	$574.50
Rate for Payer: Cash Price	$574.50
Rate for Payer: Cash Price	$574.50
Rate for Payer: CDPHP Medicare	$283.42
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$1,206.00
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$612.80
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$612.80
Rate for Payer: EmblemHealth Medicaid	$612.80
Rate for Payer: EmblemHealth Medicare	$260.44
Rate for Payer: EmblemHealth Select Care	$1,085.00
Rate for Payer: Fidelis Medicare	$306.40
Rate for Payer: Galaxy Health Commercial	$497.90
Rate for Payer: Hamaspik Choice Medicare	$306.40
Rate for Payer: Humana Medicare	$306.40
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$1,000.00
Rate for Payer: Local 1199SEIU Medicare	$352.36
Rate for Payer: MVP Health Care of NY Commercial	$1,234.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$925.00
Rate for Payer: MVP Health Care of NY Medicare	$321.72
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$1,009.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$114.90
Rate for Payer: United Healthcare Commercial	$1,009.00
Rate for Payer: United Healthcare Medicare	$306.40
Rate for Payer: WellCare Medicare	$421.30

CHARCOAL/SORBITOL SOLUTION 50GM LIQD 240

Facility

$73.13

Service Code	NDC 574012008
Hospital Charge Code	4400014
Hospital Revenue Code	250
Min. Negotiated Rate	$40.22
Max. Negotiated Rate	$47.53
Rate for Payer: Cash Price	$54.85
Rate for Payer: Galaxy Health Commercial	$47.53
Rate for Payer: WellCare Medicare	$40.22

CHARCOAL/SORBITOL SOLUTION 50GM LIQD 240

Facility

$73.13

Service Code	NDC 574012008
Hospital Charge Code	4400014
Hospital Revenue Code	250
Min. Negotiated Rate	$10.97
Max. Negotiated Rate	$58.50
Rate for Payer: Aetna of NY Commercial	$51.19
Rate for Payer: Aetna of NY Medicare	$33.64
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$29.25
Rate for Payer: Cash Price	$54.85
Rate for Payer: CDPHP Medicare	$27.06
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$58.50
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$58.50
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$58.50
Rate for Payer: EmblemHealth Medicaid	$58.50
Rate for Payer: EmblemHealth Medicare	$24.86
Rate for Payer: EmblemHealth Select Care	$52.65
Rate for Payer: Fidelis Medicare	$29.25
Rate for Payer: Galaxy Health Commercial	$47.53
Rate for Payer: Hamaspik Choice Medicare	$29.25
Rate for Payer: Humana Medicare	$29.25
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$51.19
Rate for Payer: Local 1199SEIU Medicare	$33.64
Rate for Payer: MVP Health Care of NY Commercial	$54.85
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$41.17
Rate for Payer: MVP Health Care of NY Medicare	$30.71
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$10.97
Rate for Payer: United Healthcare Medicare	$29.25
Rate for Payer: WellCare Medicare	$40.22

CHEMODENERVATION OF MUSCLE(S); MUSCLE(S) INNERVATED BY FACIAL, TRIGEMINAL, CERVICAL SPINAL AND ACCESSORY NERVES, BILATERAL (EG, FOR CHRONIC MIGRAINE)

Facility

$1,900.00

Service Code	CPT 64615
Hospital Revenue Code	490
Min. Negotiated Rate	$282.20
Max. Negotiated Rate	$1,900.00
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	$1,828.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$282.20
Rate for Payer: United Healthcare Commercial	$1,828.00

CHEMODENERVATION OF TRUNK MUSCLE(S); 6 OR MORE MUSCLES

Facility

$1,900.00

Service Code	CPT 64647
Hospital Revenue Code	490
Min. Negotiated Rate	$658.90
Max. Negotiated Rate	$1,900.00
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	$1,828.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$658.90
Rate for Payer: United Healthcare Commercial	$1,828.00

CHEMO IV INFUSION 1 HR

Facility

$1,012.00

Service Code	HCPCS 96413
Hospital Charge Code	4451254
Hospital Revenue Code	335
Min. Negotiated Rate	$151.80
Max. Negotiated Rate	$809.60
Rate for Payer: Aetna of NY Commercial	$708.40
Rate for Payer: Aetna of NY Medicare	$465.52
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$404.80
Rate for Payer: Cash Price	$759.00
Rate for Payer: CDPHP Medicare	$374.44
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$809.60
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$809.60
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$809.60
Rate for Payer: EmblemHealth Medicaid	$809.60
Rate for Payer: EmblemHealth Medicare	$344.08
Rate for Payer: EmblemHealth Select Care	$728.64
Rate for Payer: Fidelis Medicare	$404.80
Rate for Payer: Galaxy Health Commercial	$657.80
Rate for Payer: Hamaspik Choice Medicare	$404.80
Rate for Payer: Humana Medicare	$404.80
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$708.40
Rate for Payer: Local 1199SEIU Medicare	$465.52
Rate for Payer: MVP Health Care of NY Commercial	$759.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$569.76
Rate for Payer: MVP Health Care of NY Medicare	$425.04
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$151.80
Rate for Payer: United Healthcare Medicare	$404.80
Rate for Payer: WellCare Medicare	$556.60

CHEMO IV INFUSION 1 HR

Facility

$1,012.00

Service Code	HCPCS 96413
Hospital Charge Code	4451254
Hospital Revenue Code	335
Min. Negotiated Rate	$657.80
Max. Negotiated Rate	$657.80
Rate for Payer: Cash Price	$759.00
Rate for Payer: Galaxy Health Commercial	$657.80

CHEMO IV INFUSION ADDL HR

Facility

$221.00

Service Code	HCPCS 96415
Hospital Charge Code	4451255
Hospital Revenue Code	335
Min. Negotiated Rate	$33.15
Max. Negotiated Rate	$176.80
Rate for Payer: Aetna of NY Commercial	$154.70
Rate for Payer: Aetna of NY Medicare	$101.66
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$88.40
Rate for Payer: Cash Price	$165.75
Rate for Payer: CDPHP Medicare	$81.77
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$176.80
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$176.80
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$176.80
Rate for Payer: EmblemHealth Medicaid	$176.80
Rate for Payer: EmblemHealth Medicare	$75.14
Rate for Payer: EmblemHealth Select Care	$159.12
Rate for Payer: Fidelis Medicare	$88.40
Rate for Payer: Galaxy Health Commercial	$143.65
Rate for Payer: Hamaspik Choice Medicare	$88.40
Rate for Payer: Humana Medicare	$88.40
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$154.70
Rate for Payer: Local 1199SEIU Medicare	$101.66
Rate for Payer: MVP Health Care of NY Commercial	$165.75
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$124.42
Rate for Payer: MVP Health Care of NY Medicare	$92.82
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$33.15
Rate for Payer: United Healthcare Medicare	$88.40
Rate for Payer: WellCare Medicare	$121.55

CHEMO IV INFUSION ADDL HR

Facility

$221.00

Service Code	HCPCS 96415
Hospital Charge Code	4451255
Hospital Revenue Code	335
Min. Negotiated Rate	$143.65
Max. Negotiated Rate	$143.65
Rate for Payer: Cash Price	$165.75
Rate for Payer: Galaxy Health Commercial	$143.65

CHEST PHYSICAL THERAPY-INITIAL

Facility

$408.00

Service Code	HCPCS 94667
Hospital Charge Code	4530009
Hospital Revenue Code	410
Min. Negotiated Rate	$61.20
Max. Negotiated Rate	$326.40
Rate for Payer: Aetna of NY Commercial	$285.60
Rate for Payer: Aetna of NY Medicare	$187.68
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$163.20
Rate for Payer: Cash Price	$306.00
Rate for Payer: CDPHP Medicare	$150.96
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$326.40
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$326.40
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$326.40
Rate for Payer: EmblemHealth Medicaid	$326.40
Rate for Payer: EmblemHealth Medicare	$138.72
Rate for Payer: EmblemHealth Select Care	$293.76
Rate for Payer: Fidelis Medicare	$163.20
Rate for Payer: Galaxy Health Commercial	$265.20
Rate for Payer: Hamaspik Choice Medicare	$163.20
Rate for Payer: Humana Medicare	$163.20
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$285.60
Rate for Payer: Local 1199SEIU Medicare	$187.68
Rate for Payer: MVP Health Care of NY Commercial	$306.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$229.70
Rate for Payer: MVP Health Care of NY Medicare	$171.36
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$61.20
Rate for Payer: United Healthcare Medicare	$163.20
Rate for Payer: WellCare Medicare	$224.40

CHEST PHYSICAL THERAPY-INITIAL

Facility

$408.00

Service Code	HCPCS 94667
Hospital Charge Code	4530009
Hospital Revenue Code	410
Min. Negotiated Rate	$265.20
Max. Negotiated Rate	$265.20
Rate for Payer: Cash Price	$306.00
Rate for Payer: Galaxy Health Commercial	$265.20

CHEST TUBE INSERTION

Facility

$4,825.00

Service Code	HCPCS 32551
Hospital Charge Code	4600054
Hospital Revenue Code	450
Min. Negotiated Rate	$723.75
Max. Negotiated Rate	$3,860.00
Rate for Payer: Aetna of NY Commercial	$1,000.00
Rate for Payer: Aetna of NY Medicare	$2,219.50
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$1,930.00
Rate for Payer: Cash Price	$3,618.75
Rate for Payer: Cash Price	$3,618.75
Rate for Payer: Cash Price	$3,618.75
Rate for Payer: CDPHP Medicare	$1,785.25
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$1,206.00
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$3,860.00
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$3,860.00
Rate for Payer: EmblemHealth Medicaid	$3,860.00
Rate for Payer: EmblemHealth Medicare	$1,640.50
Rate for Payer: EmblemHealth Select Care	$1,085.00
Rate for Payer: Fidelis Medicare	$1,930.00
Rate for Payer: Galaxy Health Commercial	$3,136.25
Rate for Payer: Hamaspik Choice Medicare	$1,930.00
Rate for Payer: Humana Medicare	$1,930.00
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$1,000.00
Rate for Payer: Local 1199SEIU Medicare	$2,219.50
Rate for Payer: MVP Health Care of NY Commercial	$1,234.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$925.00
Rate for Payer: MVP Health Care of NY Medicare	$2,026.50
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$1,009.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$723.75
Rate for Payer: United Healthcare Commercial	$1,009.00
Rate for Payer: United Healthcare Medicare	$1,930.00
Rate for Payer: WellCare Medicare	$2,653.75

CHEST TUBE INSERTION

Facility

$4,825.00

Service Code	HCPCS 32551
Hospital Charge Code	4600054
Hospital Revenue Code	450
Min. Negotiated Rate	$3,136.25
Max. Negotiated Rate	$3,136.25
Rate for Payer: Cash Price	$3,618.75
Rate for Payer: Galaxy Health Commercial	$3,136.25

CHILDREN'S APAP SUSPENSION 160 MG/ 5 ML

Facility

$6.18

Service Code	NDC 121065705
Hospital Charge Code	4409174
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

CHILDREN'S APAP SUSPENSION 160 MG/ 5 ML

Facility

$6.18

Service Code	NDC 121065705
Hospital Charge Code	4409174
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

CHLAMYDIA T AMPLIF NA PROBE

Facility

$137.00

Service Code	HCPCS 87491
Hospital Charge Code	4304867
Hospital Revenue Code	306
Min. Negotiated Rate	$89.05
Max. Negotiated Rate	$89.05
Rate for Payer: Cash Price	$102.75
Rate for Payer: Galaxy Health Commercial	$89.05

CHLAMYDIA T AMPLIF NA PROBE

Facility

$137.00

Service Code	HCPCS 87491
Hospital Charge Code	4304867
Hospital Revenue Code	306
Min. Negotiated Rate	$20.55
Max. Negotiated Rate	$109.60
Rate for Payer: Aetna of NY Commercial	$89.05
Rate for Payer: Aetna of NY Medicare	$63.02
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$54.80
Rate for Payer: Cash Price	$102.75
Rate for Payer: CDPHP Medicare	$50.69
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$82.20
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$109.60
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$109.60
Rate for Payer: EmblemHealth Medicaid	$109.60
Rate for Payer: EmblemHealth Medicare	$46.58
Rate for Payer: EmblemHealth Select Care	$82.20
Rate for Payer: Fidelis Medicare	$54.80
Rate for Payer: Galaxy Health Commercial	$89.05
Rate for Payer: Hamaspik Choice Medicare	$54.80
Rate for Payer: Humana Medicare	$54.80
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$89.05
Rate for Payer: Local 1199SEIU Medicare	$63.02
Rate for Payer: MVP Health Care of NY Commercial	$102.75
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$77.13
Rate for Payer: MVP Health Care of NY Medicare	$57.54
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$102.75
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$20.55
Rate for Payer: United Healthcare Commercial	$102.75
Rate for Payer: United Healthcare Medicare	$54.80
Rate for Payer: WellCare Medicare	$75.35

CHLAMYDIA T DIR NA PROBE

Facility

$68.00

Service Code	HCPCS 87490
Hospital Charge Code	4301440
Hospital Revenue Code	306
Min. Negotiated Rate	$44.20
Max. Negotiated Rate	$44.20
Rate for Payer: Cash Price	$51.00
Rate for Payer: Galaxy Health Commercial	$44.20

Know your out-of-pocket cost for care.

All Charges