Ellenville Regional Hospital

All Charges

Charge

Type

Setting

Price

CL TX PHALANG SHFT FX; W MANIP

Facility

$756.00

Service Code	HCPCS 26725
Hospital Charge Code	4855441
Hospital Revenue Code	761
Min. Negotiated Rate	$491.40
Max. Negotiated Rate	$491.40
Rate for Payer: Cash Price	$567.00
Rate for Payer: Galaxy Health Commercial	$491.40

CL TX PHALANG SHFT FX; W MANIP

Facility

$756.00

Service Code	HCPCS 26725
Hospital Charge Code	4850143
Hospital Revenue Code	761
Min. Negotiated Rate	$491.40
Max. Negotiated Rate	$491.40
Rate for Payer: Cash Price	$567.00
Rate for Payer: Galaxy Health Commercial	$491.40

CLTX POST HIP ARTHRP DISLC REQ ANES

Facility

$4,928.00

Service Code	HCPCS 27266
Hospital Charge Code	4601199
Hospital Revenue Code	450
Min. Negotiated Rate	$739.20
Max. Negotiated Rate	$3,942.40
Rate for Payer: Aetna of NY Commercial	$1,000.00
Rate for Payer: Aetna of NY Medicare	$2,266.88
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$1,971.20
Rate for Payer: Cash Price	$3,696.00
Rate for Payer: Cash Price	$3,696.00
Rate for Payer: Cash Price	$3,696.00
Rate for Payer: CDPHP Medicare	$1,823.36
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$1,206.00
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$3,942.40
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$3,942.40
Rate for Payer: EmblemHealth Medicaid	$3,942.40
Rate for Payer: EmblemHealth Medicare	$1,675.52
Rate for Payer: EmblemHealth Select Care	$1,085.00
Rate for Payer: Fidelis Medicare	$1,971.20
Rate for Payer: Galaxy Health Commercial	$3,203.20
Rate for Payer: Hamaspik Choice Medicare	$1,971.20
Rate for Payer: Humana Medicare	$1,971.20
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$1,000.00
Rate for Payer: Local 1199SEIU Medicare	$2,266.88
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	$2,069.76
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$1,009.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$739.20
Rate for Payer: United Healthcare Commercial	$1,009.00
Rate for Payer: United Healthcare Medicare	$1,971.20
Rate for Payer: WellCare Medicare	$2,710.40

CLTX POST HIP ARTHRP DISLC REQ ANES

Facility

$4,928.00

Service Code	HCPCS 27266
Hospital Charge Code	4601199
Hospital Revenue Code	450
Min. Negotiated Rate	$3,203.20
Max. Negotiated Rate	$3,203.20
Rate for Payer: Cash Price	$3,696.00
Rate for Payer: Galaxy Health Commercial	$3,203.20

CLTX POST HIP ARTHRP DISLC W/O ANES

Facility

$756.00

Service Code	HCPCS 27265
Hospital Charge Code	4601200
Hospital Revenue Code	450
Min. Negotiated Rate	$491.40
Max. Negotiated Rate	$491.40
Rate for Payer: Cash Price	$567.00
Rate for Payer: Galaxy Health Commercial	$491.40

CLTX POST HIP ARTHRP DISLC W/O ANES

Facility

$756.00

Service Code	HCPCS 27265
Hospital Charge Code	4601200
Hospital Revenue Code	450
Min. Negotiated Rate	$113.40
Max. Negotiated Rate	$1,234.00
Rate for Payer: Aetna of NY Commercial	$1,000.00
Rate for Payer: Aetna of NY Medicare	$347.76
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$302.40
Rate for Payer: Cash Price	$567.00
Rate for Payer: Cash Price	$567.00
Rate for Payer: Cash Price	$567.00
Rate for Payer: CDPHP Medicare	$279.72
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$1,206.00
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$604.80
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$604.80
Rate for Payer: EmblemHealth Medicaid	$604.80
Rate for Payer: EmblemHealth Medicare	$257.04
Rate for Payer: EmblemHealth Select Care	$1,085.00
Rate for Payer: Fidelis Medicare	$302.40
Rate for Payer: Galaxy Health Commercial	$491.40
Rate for Payer: Hamaspik Choice Medicare	$302.40
Rate for Payer: Humana Medicare	$302.40
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$1,000.00
Rate for Payer: Local 1199SEIU Medicare	$347.76
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	$317.52
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$1,009.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$113.40
Rate for Payer: United Healthcare Commercial	$1,009.00
Rate for Payer: United Healthcare Medicare	$302.40
Rate for Payer: WellCare Medicare	$415.80

CLTX PROX FIBULA/SHFT FX W/MANJ

Facility

$4,928.00

Service Code	HCPCS 27781
Hospital Charge Code	4602223
Hospital Revenue Code	450
Min. Negotiated Rate	$3,203.20
Max. Negotiated Rate	$3,203.20
Rate for Payer: Cash Price	$3,696.00
Rate for Payer: Galaxy Health Commercial	$3,203.20

CLTX PROX FIBULA/SHFT FX W/MANJ

Facility

$4,928.00

Service Code	HCPCS 27781
Hospital Charge Code	4602223
Hospital Revenue Code	450
Min. Negotiated Rate	$739.20
Max. Negotiated Rate	$3,942.40
Rate for Payer: Aetna of NY Commercial	$1,000.00
Rate for Payer: Aetna of NY Medicare	$2,266.88
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$1,971.20
Rate for Payer: Cash Price	$3,696.00
Rate for Payer: Cash Price	$3,696.00
Rate for Payer: Cash Price	$3,696.00
Rate for Payer: CDPHP Medicare	$1,823.36
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$1,206.00
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$3,942.40
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$3,942.40
Rate for Payer: EmblemHealth Medicaid	$3,942.40
Rate for Payer: EmblemHealth Medicare	$1,675.52
Rate for Payer: EmblemHealth Select Care	$1,085.00
Rate for Payer: Fidelis Medicare	$1,971.20
Rate for Payer: Galaxy Health Commercial	$3,203.20
Rate for Payer: Hamaspik Choice Medicare	$1,971.20
Rate for Payer: Humana Medicare	$1,971.20
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$1,000.00
Rate for Payer: Local 1199SEIU Medicare	$2,266.88
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	$2,069.76
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$1,009.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$739.20
Rate for Payer: United Healthcare Commercial	$1,009.00
Rate for Payer: United Healthcare Medicare	$1,971.20
Rate for Payer: WellCare Medicare	$2,710.40

CL TX SC/TX HUMERUS SHFT FX W MANIP

Facility

$4,928.00

Service Code	HCPCS 24535
Hospital Charge Code	4850202
Hospital Revenue Code	761
Min. Negotiated Rate	$739.20
Max. Negotiated Rate	$3,942.40
Rate for Payer: Aetna of NY Commercial	$3,449.60
Rate for Payer: Aetna of NY Medicare	$2,266.88
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$1,971.20
Rate for Payer: Cash Price	$3,696.00
Rate for Payer: CDPHP Medicare	$1,823.36
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$3,942.40
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$3,942.40
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$3,942.40
Rate for Payer: EmblemHealth Medicaid	$3,942.40
Rate for Payer: EmblemHealth Medicare	$1,675.52
Rate for Payer: EmblemHealth Select Care	$3,548.16
Rate for Payer: Fidelis Medicare	$1,971.20
Rate for Payer: Galaxy Health Commercial	$3,203.20
Rate for Payer: Hamaspik Choice Medicare	$1,971.20
Rate for Payer: Humana Medicare	$1,971.20
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$3,449.60
Rate for Payer: Local 1199SEIU Medicare	$2,266.88
Rate for Payer: MVP Health Care of NY Commercial	$3,696.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$2,774.46
Rate for Payer: MVP Health Care of NY Medicare	$2,069.76
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$739.20
Rate for Payer: United Healthcare Medicare	$1,971.20
Rate for Payer: WellCare Medicare	$2,710.40

CL TX SC/TX HUMERUS SHFT FX W MANIP

Facility

$4,928.00

Service Code	HCPCS 24535
Hospital Charge Code	4850202
Hospital Revenue Code	761
Min. Negotiated Rate	$3,203.20
Max. Negotiated Rate	$3,203.20
Rate for Payer: Cash Price	$3,696.00
Rate for Payer: Galaxy Health Commercial	$3,203.20

CL TX TIB SHFT FX W MANIP

Facility

$4,928.00

Service Code	HCPCS 27752
Hospital Charge Code	4609661
Hospital Revenue Code	450
Min. Negotiated Rate	$3,203.20
Max. Negotiated Rate	$3,203.20
Rate for Payer: Cash Price	$3,696.00
Rate for Payer: Galaxy Health Commercial	$3,203.20

CL TX TIB SHFT FX W MANIP

Facility

$4,928.00

Service Code	HCPCS 27752
Hospital Charge Code	4609661
Hospital Revenue Code	450
Min. Negotiated Rate	$739.20
Max. Negotiated Rate	$3,942.40
Rate for Payer: Aetna of NY Commercial	$1,000.00
Rate for Payer: Aetna of NY Medicare	$2,266.88
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$1,971.20
Rate for Payer: Cash Price	$3,696.00
Rate for Payer: Cash Price	$3,696.00
Rate for Payer: Cash Price	$3,696.00
Rate for Payer: CDPHP Medicare	$1,823.36
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$1,206.00
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$3,942.40
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$3,942.40
Rate for Payer: EmblemHealth Medicaid	$3,942.40
Rate for Payer: EmblemHealth Medicare	$1,675.52
Rate for Payer: EmblemHealth Select Care	$1,085.00
Rate for Payer: Fidelis Medicare	$1,971.20
Rate for Payer: Galaxy Health Commercial	$3,203.20
Rate for Payer: Hamaspik Choice Medicare	$1,971.20
Rate for Payer: Humana Medicare	$1,971.20
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$1,000.00
Rate for Payer: Local 1199SEIU Medicare	$2,266.88
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	$2,069.76
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$1,009.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$739.20
Rate for Payer: United Healthcare Commercial	$1,009.00
Rate for Payer: United Healthcare Medicare	$1,971.20
Rate for Payer: WellCare Medicare	$2,710.40

CL TX TIB SHFT FX W MANIP

Facility

$4,928.00

Service Code	HCPCS 27752
Hospital Charge Code	4850305
Hospital Revenue Code	761
Min. Negotiated Rate	$3,203.20
Max. Negotiated Rate	$3,203.20
Rate for Payer: Cash Price	$3,696.00
Rate for Payer: Galaxy Health Commercial	$3,203.20

CL TX TIB SHFT FX W MANIP

Facility

$4,928.00

Service Code	HCPCS 27752
Hospital Charge Code	4850305
Hospital Revenue Code	761
Min. Negotiated Rate	$739.20
Max. Negotiated Rate	$3,942.40
Rate for Payer: Aetna of NY Commercial	$3,449.60
Rate for Payer: Aetna of NY Medicare	$2,266.88
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$1,971.20
Rate for Payer: Cash Price	$3,696.00
Rate for Payer: CDPHP Medicare	$1,823.36
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$3,942.40
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$3,942.40
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$3,942.40
Rate for Payer: EmblemHealth Medicaid	$3,942.40
Rate for Payer: EmblemHealth Medicare	$1,675.52
Rate for Payer: EmblemHealth Select Care	$3,548.16
Rate for Payer: Fidelis Medicare	$1,971.20
Rate for Payer: Galaxy Health Commercial	$3,203.20
Rate for Payer: Hamaspik Choice Medicare	$1,971.20
Rate for Payer: Humana Medicare	$1,971.20
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$3,449.60
Rate for Payer: Local 1199SEIU Medicare	$2,266.88
Rate for Payer: MVP Health Care of NY Commercial	$3,696.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$2,774.46
Rate for Payer: MVP Health Care of NY Medicare	$2,069.76
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$739.20
Rate for Payer: United Healthcare Medicare	$1,971.20
Rate for Payer: WellCare Medicare	$2,710.40

CLTX TRIMALLEOLAR ANKLE FX W/MANIPULATION

Facility

$4,928.00

Service Code	HCPCS 27818
Hospital Charge Code	4602232
Hospital Revenue Code	450
Min. Negotiated Rate	$3,203.20
Max. Negotiated Rate	$3,203.20
Rate for Payer: Cash Price	$3,696.00
Rate for Payer: Galaxy Health Commercial	$3,203.20

CLTX TRIMALLEOLAR ANKLE FX W/MANIPULATION

Facility

$4,928.00

Service Code	HCPCS 27818
Hospital Charge Code	4602232
Hospital Revenue Code	450
Min. Negotiated Rate	$739.20
Max. Negotiated Rate	$3,942.40
Rate for Payer: Aetna of NY Commercial	$1,000.00
Rate for Payer: Aetna of NY Medicare	$2,266.88
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$1,971.20
Rate for Payer: Cash Price	$3,696.00
Rate for Payer: Cash Price	$3,696.00
Rate for Payer: Cash Price	$3,696.00
Rate for Payer: CDPHP Medicare	$1,823.36
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$1,206.00
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$3,942.40
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$3,942.40
Rate for Payer: EmblemHealth Medicaid	$3,942.40
Rate for Payer: EmblemHealth Medicare	$1,675.52
Rate for Payer: EmblemHealth Select Care	$1,085.00
Rate for Payer: Fidelis Medicare	$1,971.20
Rate for Payer: Galaxy Health Commercial	$3,203.20
Rate for Payer: Hamaspik Choice Medicare	$1,971.20
Rate for Payer: Humana Medicare	$1,971.20
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$1,000.00
Rate for Payer: Local 1199SEIU Medicare	$2,266.88
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	$2,069.76
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$1,009.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$739.20
Rate for Payer: United Healthcare Commercial	$1,009.00
Rate for Payer: United Healthcare Medicare	$1,971.20
Rate for Payer: WellCare Medicare	$2,710.40

CLTX TRIMALLEOLAR ANKLE FX W/MANIPULATION

Facility

$4,928.00

Service Code	HCPCS 27818
Hospital Charge Code	4601202
Hospital Revenue Code	450
Min. Negotiated Rate	$3,203.20
Max. Negotiated Rate	$3,203.20
Rate for Payer: Cash Price	$3,696.00
Rate for Payer: Galaxy Health Commercial	$3,203.20

CLTX TRIMALLEOLAR ANKLE FX W/MANIPULATION

Facility

$4,928.00

Service Code	HCPCS 27818
Hospital Charge Code	4601202
Hospital Revenue Code	450
Min. Negotiated Rate	$739.20
Max. Negotiated Rate	$3,942.40
Rate for Payer: Aetna of NY Commercial	$1,000.00
Rate for Payer: Aetna of NY Medicare	$2,266.88
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$1,971.20
Rate for Payer: Cash Price	$3,696.00
Rate for Payer: Cash Price	$3,696.00
Rate for Payer: Cash Price	$3,696.00
Rate for Payer: CDPHP Medicare	$1,823.36
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$1,206.00
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$3,942.40
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$3,942.40
Rate for Payer: EmblemHealth Medicaid	$3,942.40
Rate for Payer: EmblemHealth Medicare	$1,675.52
Rate for Payer: EmblemHealth Select Care	$1,085.00
Rate for Payer: Fidelis Medicare	$1,971.20
Rate for Payer: Galaxy Health Commercial	$3,203.20
Rate for Payer: Hamaspik Choice Medicare	$1,971.20
Rate for Payer: Humana Medicare	$1,971.20
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$1,000.00
Rate for Payer: Local 1199SEIU Medicare	$2,266.88
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	$2,069.76
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$1,009.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$739.20
Rate for Payer: United Healthcare Commercial	$1,009.00
Rate for Payer: United Healthcare Medicare	$1,971.20
Rate for Payer: WellCare Medicare	$2,710.40

CL TX WB DSTL TIB FX W MANIP

Facility

$4,928.00

Service Code	HCPCS 27825
Hospital Charge Code	4852001
Hospital Revenue Code	761
Min. Negotiated Rate	$739.20
Max. Negotiated Rate	$3,942.40
Rate for Payer: Aetna of NY Commercial	$3,449.60
Rate for Payer: Aetna of NY Medicare	$2,266.88
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$1,971.20
Rate for Payer: Cash Price	$3,696.00
Rate for Payer: CDPHP Medicare	$1,823.36
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$3,942.40
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$3,942.40
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$3,942.40
Rate for Payer: EmblemHealth Medicaid	$3,942.40
Rate for Payer: EmblemHealth Medicare	$1,675.52
Rate for Payer: EmblemHealth Select Care	$3,548.16
Rate for Payer: Fidelis Medicare	$1,971.20
Rate for Payer: Galaxy Health Commercial	$3,203.20
Rate for Payer: Hamaspik Choice Medicare	$1,971.20
Rate for Payer: Humana Medicare	$1,971.20
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$3,449.60
Rate for Payer: Local 1199SEIU Medicare	$2,266.88
Rate for Payer: MVP Health Care of NY Commercial	$3,696.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$2,774.46
Rate for Payer: MVP Health Care of NY Medicare	$2,069.76
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$739.20
Rate for Payer: United Healthcare Medicare	$1,971.20
Rate for Payer: WellCare Medicare	$2,710.40

CL TX WB DSTL TIB FX W MANIP

Facility

$4,928.00

Service Code	HCPCS 27825
Hospital Charge Code	4852001
Hospital Revenue Code	761
Min. Negotiated Rate	$3,203.20
Max. Negotiated Rate	$3,203.20
Rate for Payer: Cash Price	$3,696.00
Rate for Payer: Galaxy Health Commercial	$3,203.20

CODEINE/ACETAMIN 12-120MG/5ML ELIX 100X5

Facility

$6.18

Service Code	NDC 121050405
Hospital Charge Code	4400006
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

CODEINE/ACETAMIN 12-120MG/5ML ELIX 100X5

Facility

$6.18

Service Code	NDC 121050405
Hospital Charge Code	4400006
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

CODEINE/ACETAMIN 30-300MG TABS 100 EA

Facility

$6.18

Service Code	NDC 68084037201
Hospital Charge Code	4400007
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

CODEINE/ACETAMIN 30-300MG TABS 100 EA

Facility

$6.18

Service Code	NDC 68084037201
Hospital Charge Code	4400007
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

CO DIFFUSING CAPACITY

Facility

$221.00

Service Code	HCPCS 94729
Hospital Charge Code	4530010
Hospital Revenue Code	460
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	$154.70
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	$143.65
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

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