Ellenville Regional Hospital

All Charges

Charge

Type

Setting

Price

EZY SPLINT ROLL 2"

Facility

$20.60

Hospital Charge Code	4472010
Hospital Revenue Code	270
Min. Negotiated Rate	$13.39
Max. Negotiated Rate	$13.39
Rate for Payer: Cash Price	$15.45
Rate for Payer: Galaxy Health Commercial	$13.39

EZY SPLINT ROLL 2"

Facility

$20.60

Hospital Charge Code	4472010
Hospital Revenue Code	270
Min. Negotiated Rate	$3.09
Max. Negotiated Rate	$16.48
Rate for Payer: Aetna of NY Commercial	$14.42
Rate for Payer: Aetna of NY Medicare	$9.48
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$8.24
Rate for Payer: Cash Price	$15.45
Rate for Payer: CDPHP Medicare	$7.62
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$16.48
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$16.48
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$16.48
Rate for Payer: EmblemHealth Medicaid	$16.48
Rate for Payer: EmblemHealth Medicare	$7.00
Rate for Payer: EmblemHealth Select Care	$14.83
Rate for Payer: Fidelis Medicare	$8.24
Rate for Payer: Galaxy Health Commercial	$13.39
Rate for Payer: Hamaspik Choice Medicare	$8.24
Rate for Payer: Humana Medicare	$8.24
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$14.42
Rate for Payer: Local 1199SEIU Medicare	$9.48
Rate for Payer: MVP Health Care of NY Commercial	$15.45
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$11.60
Rate for Payer: MVP Health Care of NY Medicare	$8.65
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$3.09
Rate for Payer: United Healthcare Medicare	$8.24
Rate for Payer: WellCare Medicare	$11.33

EZY SPLINT ROLL 3"

Facility

$25.75

Hospital Charge Code	4472011
Hospital Revenue Code	270
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

EZY SPLINT ROLL 3"

Facility

$25.75

Hospital Charge Code	4472011
Hospital Revenue Code	270
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

EZY SPLINT ROLL 4"

Facility

$31.93

Hospital Charge Code	4472012
Hospital Revenue Code	270
Min. Negotiated Rate	$20.75
Max. Negotiated Rate	$20.75
Rate for Payer: Cash Price	$23.95
Rate for Payer: Galaxy Health Commercial	$20.75

EZY SPLINT ROLL 4"

Facility

$31.93

Hospital Charge Code	4472012
Hospital Revenue Code	270
Min. Negotiated Rate	$4.79
Max. Negotiated Rate	$25.54
Rate for Payer: Aetna of NY Commercial	$22.35
Rate for Payer: Aetna of NY Medicare	$14.69
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$12.77
Rate for Payer: Cash Price	$23.95
Rate for Payer: CDPHP Medicare	$11.81
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$25.54
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$25.54
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$25.54
Rate for Payer: EmblemHealth Medicaid	$25.54
Rate for Payer: EmblemHealth Medicare	$10.86
Rate for Payer: EmblemHealth Select Care	$22.99
Rate for Payer: Fidelis Medicare	$12.77
Rate for Payer: Galaxy Health Commercial	$20.75
Rate for Payer: Hamaspik Choice Medicare	$12.77
Rate for Payer: Humana Medicare	$12.77
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$22.35
Rate for Payer: Local 1199SEIU Medicare	$14.69
Rate for Payer: MVP Health Care of NY Commercial	$23.95
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$17.98
Rate for Payer: MVP Health Care of NY Medicare	$13.41
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$4.79
Rate for Payer: United Healthcare Medicare	$12.77
Rate for Payer: WellCare Medicare	$17.56

EZY SPLINT ROLL 5"

Facility

$39.14

Hospital Charge Code	4472008
Hospital Revenue Code	270
Min. Negotiated Rate	$5.87
Max. Negotiated Rate	$31.31
Rate for Payer: Aetna of NY Commercial	$27.40
Rate for Payer: Aetna of NY Medicare	$18.00
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$15.66
Rate for Payer: Cash Price	$29.36
Rate for Payer: CDPHP Medicare	$14.48
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$31.31
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$31.31
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$31.31
Rate for Payer: EmblemHealth Medicaid	$31.31
Rate for Payer: EmblemHealth Medicare	$13.31
Rate for Payer: EmblemHealth Select Care	$28.18
Rate for Payer: Fidelis Medicare	$15.66
Rate for Payer: Galaxy Health Commercial	$25.44
Rate for Payer: Hamaspik Choice Medicare	$15.66
Rate for Payer: Humana Medicare	$15.66
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$27.40
Rate for Payer: Local 1199SEIU Medicare	$18.00
Rate for Payer: MVP Health Care of NY Commercial	$29.36
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$22.04
Rate for Payer: MVP Health Care of NY Medicare	$16.44
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$5.87
Rate for Payer: United Healthcare Medicare	$15.66
Rate for Payer: WellCare Medicare	$21.53

EZY SPLINT ROLL 5"

Facility

$39.14

Hospital Charge Code	4472008
Hospital Revenue Code	270
Min. Negotiated Rate	$25.44
Max. Negotiated Rate	$25.44
Rate for Payer: Cash Price	$29.36
Rate for Payer: Galaxy Health Commercial	$25.44

FACTOR V LEIDEN

Facility

$53.00

Service Code	HCPCS 85220
Hospital Charge Code	4300335
Hospital Revenue Code	305
Min. Negotiated Rate	$7.95
Max. Negotiated Rate	$42.40
Rate for Payer: Aetna of NY Commercial	$34.45
Rate for Payer: Aetna of NY Medicare	$24.38
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$21.20
Rate for Payer: Cash Price	$39.75
Rate for Payer: CDPHP Medicare	$19.61
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$31.80
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$42.40
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$42.40
Rate for Payer: EmblemHealth Medicaid	$42.40
Rate for Payer: EmblemHealth Medicare	$18.02
Rate for Payer: EmblemHealth Select Care	$31.80
Rate for Payer: Fidelis Medicare	$21.20
Rate for Payer: Galaxy Health Commercial	$34.45
Rate for Payer: Hamaspik Choice Medicare	$21.20
Rate for Payer: Humana Medicare	$21.20
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$34.45
Rate for Payer: Local 1199SEIU Medicare	$24.38
Rate for Payer: MVP Health Care of NY Commercial	$39.75
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$29.84
Rate for Payer: MVP Health Care of NY Medicare	$22.26
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$39.75
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$7.95
Rate for Payer: United Healthcare Commercial	$39.75
Rate for Payer: United Healthcare Medicare	$21.20
Rate for Payer: WellCare Medicare	$29.15

FACTOR V LEIDEN

Facility

$53.00

Service Code	HCPCS 85220
Hospital Charge Code	4300335
Hospital Revenue Code	305
Min. Negotiated Rate	$34.45
Max. Negotiated Rate	$34.45
Rate for Payer: Cash Price	$39.75
Rate for Payer: Galaxy Health Commercial	$34.45

FALOPE RING BANDS,30 PROCEDURE

Facility

$55.62

Hospital Charge Code	4479086
Hospital Revenue Code	270
Min. Negotiated Rate	$8.34
Max. Negotiated Rate	$44.50
Rate for Payer: Aetna of NY Commercial	$38.93
Rate for Payer: Aetna of NY Medicare	$25.59
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$22.25
Rate for Payer: Cash Price	$41.72
Rate for Payer: CDPHP Medicare	$20.58
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$44.50
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$44.50
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$44.50
Rate for Payer: EmblemHealth Medicaid	$44.50
Rate for Payer: EmblemHealth Medicare	$18.91
Rate for Payer: EmblemHealth Select Care	$40.05
Rate for Payer: Fidelis Medicare	$22.25
Rate for Payer: Galaxy Health Commercial	$36.15
Rate for Payer: Hamaspik Choice Medicare	$22.25
Rate for Payer: Humana Medicare	$22.25
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$38.93
Rate for Payer: Local 1199SEIU Medicare	$25.59
Rate for Payer: MVP Health Care of NY Commercial	$41.72
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$31.31
Rate for Payer: MVP Health Care of NY Medicare	$23.36
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$8.34
Rate for Payer: United Healthcare Medicare	$22.25
Rate for Payer: WellCare Medicare	$30.59

FALOPE RING BANDS,30 PROCEDURE

Facility

$55.62

Hospital Charge Code	4479086
Hospital Revenue Code	270
Min. Negotiated Rate	$36.15
Max. Negotiated Rate	$36.15
Rate for Payer: Cash Price	$41.72
Rate for Payer: Galaxy Health Commercial	$36.15

FAMOTIDINE 10MG/ML SDPF 25X2ML

Facility

$6.18

Service Code	HCPCS J3490
Hospital Charge Code	4400284
Hospital Revenue Code	636
Min. Negotiated Rate	$3.40
Max. Negotiated Rate	$4.02
Rate for Payer: Aetna of NY Commercial	$3.40
Rate for Payer: Cash Price	$4.64
Rate for Payer: Galaxy Health Commercial	$4.02
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$3.40
Rate for Payer: WellCare Medicare	$3.40

FAMOTIDINE 10MG/ML SDPF 25X2ML

Facility

$6.18

Service Code	HCPCS J3490
Hospital Charge Code	4400284
Hospital Revenue Code	636
Min. Negotiated Rate	$0.93
Max. Negotiated Rate	$4.94
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 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

FAMOTIDINE 20MG TABS 100 EA

Facility

$6.18

Service Code	NDC 172572860
Hospital Charge Code	4400285
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

FAMOTIDINE 20MG TABS 100 EA

Facility

$6.18

Service Code	NDC 172572860
Hospital Charge Code	4400285
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

FASCIECTOMY, PLANTAR FASCIA; PARTIAL (SEPARATE PROCEDURE)

Facility

$3,084.03

Service Code	CPT 28060
Hospital Revenue Code	490
Min. Negotiated Rate	$1,900.00
Max. Negotiated Rate	$3,084.03
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	$2,097.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$3,084.03
Rate for Payer: United Healthcare Commercial	$2,097.00

FEMORAL VENA CAVA FILTER

Facility

$5,706.20

Hospital Charge Code	4471879
Hospital Revenue Code	270
Min. Negotiated Rate	$855.93
Max. Negotiated Rate	$4,564.96
Rate for Payer: Aetna of NY Commercial	$3,994.34
Rate for Payer: Aetna of NY Medicare	$2,624.85
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$2,282.48
Rate for Payer: Cash Price	$4,279.65
Rate for Payer: CDPHP Medicare	$2,111.29
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$4,564.96
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$4,564.96
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$4,564.96
Rate for Payer: EmblemHealth Medicaid	$4,564.96
Rate for Payer: EmblemHealth Medicare	$1,940.11
Rate for Payer: EmblemHealth Select Care	$4,108.46
Rate for Payer: Fidelis Medicare	$2,282.48
Rate for Payer: Galaxy Health Commercial	$3,709.03
Rate for Payer: Hamaspik Choice Medicare	$2,282.48
Rate for Payer: Humana Medicare	$2,282.48
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$3,994.34
Rate for Payer: Local 1199SEIU Medicare	$2,624.85
Rate for Payer: MVP Health Care of NY Commercial	$4,279.65
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$3,212.59
Rate for Payer: MVP Health Care of NY Medicare	$2,396.60
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$855.93
Rate for Payer: United Healthcare Medicare	$2,282.48
Rate for Payer: WellCare Medicare	$3,138.41

FEMORAL VENA CAVA FILTER

Facility

$5,706.20

Hospital Charge Code	4471879
Hospital Revenue Code	270
Min. Negotiated Rate	$3,709.03
Max. Negotiated Rate	$3,709.03
Rate for Payer: Cash Price	$4,279.65
Rate for Payer: Galaxy Health Commercial	$3,709.03

FENOFIBRATE 48 MG TABLET 1 ea, 1 each

Facility

$6.00

Service Code	NDC 68084063511
Hospital Charge Code	4401457
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

FENOFIBRATE 48 MG TABLET 1 ea, 1 each

Facility

$6.00

Service Code	NDC 68084063511
Hospital Charge Code	4401457
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

FENTANYL 100MCG/HR PTCH 5 EA

Facility

$190.55

Service Code	NDC 60505700902
Hospital Charge Code	4400286
Hospital Revenue Code	250
Min. Negotiated Rate	$104.80
Max. Negotiated Rate	$123.86
Rate for Payer: Cash Price	$142.91
Rate for Payer: Galaxy Health Commercial	$123.86
Rate for Payer: WellCare Medicare	$104.80

FENTANYL 100MCG/HR PTCH 5 EA

Facility

$190.55

Service Code	NDC 60505700902
Hospital Charge Code	4400286
Hospital Revenue Code	250
Min. Negotiated Rate	$28.58
Max. Negotiated Rate	$152.44
Rate for Payer: Aetna of NY Commercial	$133.38
Rate for Payer: Aetna of NY Medicare	$87.65
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$76.22
Rate for Payer: Cash Price	$142.91
Rate for Payer: CDPHP Medicare	$70.50
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$152.44
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$152.44
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$152.44
Rate for Payer: EmblemHealth Medicaid	$152.44
Rate for Payer: EmblemHealth Medicare	$64.79
Rate for Payer: EmblemHealth Select Care	$137.20
Rate for Payer: Fidelis Medicare	$76.22
Rate for Payer: Galaxy Health Commercial	$123.86
Rate for Payer: Hamaspik Choice Medicare	$76.22
Rate for Payer: Humana Medicare	$76.22
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$133.38
Rate for Payer: Local 1199SEIU Medicare	$87.65
Rate for Payer: MVP Health Care of NY Commercial	$142.91
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$107.28
Rate for Payer: MVP Health Care of NY Medicare	$80.03
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$28.58
Rate for Payer: United Healthcare Medicare	$76.22
Rate for Payer: WellCare Medicare	$104.80

FENTANYL 25MCG/HR PTCH 5 EA

Facility

$51.50

Service Code	NDC 60505700602
Hospital Charge Code	4400287
Hospital Revenue Code	250
Min. Negotiated Rate	$28.32
Max. Negotiated Rate	$33.48
Rate for Payer: Cash Price	$38.62
Rate for Payer: Galaxy Health Commercial	$33.48
Rate for Payer: WellCare Medicare	$28.32

FENTANYL 25MCG/HR PTCH 5 EA

Facility

$51.50

Service Code	NDC 60505700602
Hospital Charge Code	4400287
Hospital Revenue Code	250
Min. Negotiated Rate	$7.72
Max. Negotiated Rate	$41.20
Rate for Payer: Aetna of NY Commercial	$36.05
Rate for Payer: Aetna of NY Medicare	$23.69
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$20.60
Rate for Payer: Cash Price	$38.62
Rate for Payer: CDPHP Medicare	$19.05
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$41.20
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$41.20
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$41.20
Rate for Payer: EmblemHealth Medicaid	$41.20
Rate for Payer: EmblemHealth Medicare	$17.51
Rate for Payer: EmblemHealth Select Care	$37.08
Rate for Payer: Fidelis Medicare	$20.60
Rate for Payer: Galaxy Health Commercial	$33.48
Rate for Payer: Hamaspik Choice Medicare	$20.60
Rate for Payer: Humana Medicare	$20.60
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$36.05
Rate for Payer: Local 1199SEIU Medicare	$23.69
Rate for Payer: MVP Health Care of NY Commercial	$38.62
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$28.99
Rate for Payer: MVP Health Care of NY Medicare	$21.63
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$7.72
Rate for Payer: United Healthcare Medicare	$20.60
Rate for Payer: WellCare Medicare	$28.32

Know your out-of-pocket cost for care.

All Charges