Ellenville Regional Hospital

All Charges

Charge

Type

Setting

Price

INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; INTERCOSTAL NERVE, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

Facility

$1,900.00

Service Code	CPT 64421
Hospital Revenue Code	490
Min. Negotiated Rate	$868.45
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	$868.45
Rate for Payer: United Healthcare Commercial	$1,828.00

INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; INTERCOSTAL NERVE, SINGLE LEVEL

Facility

$1,900.00

Service Code	CPT 64420
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

INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; OTHER PERIPHERAL NERVE OR BRANCH

Facility

$1,900.00

Service Code	CPT 64450
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

INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

Facility

$1,900.00

Service Code	CPT 64484
Hospital Revenue Code	490
Min. Negotiated Rate	$50.93
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	$50.93
Rate for Payer: United Healthcare Commercial	$1,828.00

INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, SINGLE LEVEL

Facility

$1,900.00

Service Code	CPT 64483
Hospital Revenue Code	490
Min. Negotiated Rate	$868.45
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	$868.45
Rate for Payer: United Healthcare Commercial	$1,828.00

INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

Facility

$1,900.00

Service Code	CPT 64491
Hospital Revenue Code	490
Min. Negotiated Rate	$58.59
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	$58.59
Rate for Payer: United Healthcare Commercial	$1,828.00

INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC; SINGLE LEVEL

Facility

$1,900.00

Service Code	CPT 64490
Hospital Revenue Code	490
Min. Negotiated Rate	$868.45
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	$868.45
Rate for Payer: United Healthcare Commercial	$1,828.00

INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC; THIRD AND ANY ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

Facility

$1,900.00

Service Code	CPT 64492
Hospital Revenue Code	490
Min. Negotiated Rate	$59.58
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	$59.58
Rate for Payer: United Healthcare Commercial	$1,828.00

INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

Facility

$1,900.00

Service Code	CPT 64494
Hospital Revenue Code	490
Min. Negotiated Rate	$50.26
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	$50.26
Rate for Payer: United Healthcare Commercial	$1,828.00

INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SINGLE LEVEL

Facility

$1,900.00

Service Code	CPT 64493
Hospital Revenue Code	490
Min. Negotiated Rate	$868.45
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	$868.45
Rate for Payer: United Healthcare Commercial	$1,828.00

INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; THIRD AND ANY ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

Facility

$1,900.00

Service Code	CPT 64495
Hospital Revenue Code	490
Min. Negotiated Rate	$51.26
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	$51.26
Rate for Payer: United Healthcare Commercial	$1,828.00

INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INTERLAMINAR EPIDURAL OR SUBARACHNOID, CERVICAL OR THORACIC; WITH IMAGING GUIDANCE (IE, FLUOROSCOPY OR CT)

Facility

$1,900.00

Service Code	CPT 62321
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

INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INTERLAMINAR EPIDURAL OR SUBARACHNOID, LUMBAR OR SACRAL (CAUDAL); WITH IMAGING GUIDANCE (IE, FLUOROSCOPY OR CT)

Facility

$1,900.00

Service Code	CPT 62323
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

INJECTION, SOLU-MedroL 125 mg

Facility

$1.50

Service Code	HCPCS J2919
Hospital Charge Code	4401948
Hospital Revenue Code	636
Min. Negotiated Rate	$0.23
Max. Negotiated Rate	$1.20
Rate for Payer: Aetna of NY Medicare	$0.69
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$0.60
Rate for Payer: Cash Price	$1.12
Rate for Payer: Cash Price	$1.12
Rate for Payer: CDPHP Medicare	$0.56
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$0.24
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$1.20
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$1.20
Rate for Payer: EmblemHealth Medicaid	$1.20
Rate for Payer: EmblemHealth Medicare	$0.51
Rate for Payer: EmblemHealth Select Care	$0.24
Rate for Payer: Fidelis Medicare	$0.60
Rate for Payer: Galaxy Health Commercial	$0.98
Rate for Payer: Hamaspik Choice Medicare	$0.60
Rate for Payer: Humana Medicare	$0.60
Rate for Payer: Local 1199SEIU Medicare	$0.69
Rate for Payer: MVP Health Care of NY Commercial	$1.12
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$0.84
Rate for Payer: MVP Health Care of NY Medicare	$0.63
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$0.23
Rate for Payer: United Healthcare Medicare	$0.60
Rate for Payer: WellCare Medicare	$0.83

INJECTION, SOLU-MedroL 125 mg

Facility

$1.50

Service Code	HCPCS J2919
Hospital Charge Code	4401948
Hospital Revenue Code	636
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$0.98
Rate for Payer: Aetna of NY Commercial	$0.83
Rate for Payer: Cash Price	$1.12
Rate for Payer: Cash Price	$1.12
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$0.24
Rate for Payer: EmblemHealth Select Care	$0.24
Rate for Payer: Galaxy Health Commercial	$0.98
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$0.83
Rate for Payer: WellCare Medicare	$0.83

INJECTION, SOLU-MedroL 1 gm

Facility

$0.60

Service Code	HCPCS J2919
Hospital Charge Code	4401947
Hospital Revenue Code	636
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$0.39
Rate for Payer: Aetna of NY Commercial	$0.33
Rate for Payer: Cash Price	$0.45
Rate for Payer: Cash Price	$0.45
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$0.24
Rate for Payer: EmblemHealth Select Care	$0.24
Rate for Payer: Galaxy Health Commercial	$0.39
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$0.33
Rate for Payer: WellCare Medicare	$0.33

INJECTION, SOLU-MedroL 1 gm

Facility

$0.60

Service Code	HCPCS J2919
Hospital Charge Code	4401947
Hospital Revenue Code	636
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.48
Rate for Payer: Aetna of NY Medicare	$0.28
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$0.24
Rate for Payer: Cash Price	$0.45
Rate for Payer: Cash Price	$0.45
Rate for Payer: CDPHP Medicare	$0.22
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$0.24
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$0.48
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$0.48
Rate for Payer: EmblemHealth Medicaid	$0.48
Rate for Payer: EmblemHealth Medicare	$0.20
Rate for Payer: EmblemHealth Select Care	$0.24
Rate for Payer: Fidelis Medicare	$0.24
Rate for Payer: Galaxy Health Commercial	$0.39
Rate for Payer: Hamaspik Choice Medicare	$0.24
Rate for Payer: Humana Medicare	$0.24
Rate for Payer: Local 1199SEIU Medicare	$0.28
Rate for Payer: MVP Health Care of NY Commercial	$0.45
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$0.34
Rate for Payer: MVP Health Care of NY Medicare	$0.25
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$0.09
Rate for Payer: United Healthcare Medicare	$0.24
Rate for Payer: WellCare Medicare	$0.33

INJECTION, SOLU-MedroL 5 mg

Facility

$3.00

Service Code	HCPCS J2919
Hospital Charge Code	4401949
Hospital Revenue Code	636
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$1.95
Rate for Payer: Aetna of NY Commercial	$1.65
Rate for Payer: Cash Price	$2.25
Rate for Payer: Cash Price	$2.25
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$0.24
Rate for Payer: EmblemHealth Select Care	$0.24
Rate for Payer: Galaxy Health Commercial	$1.95
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$1.65
Rate for Payer: WellCare Medicare	$1.65

INJECTION, SOLU-MedroL 5 mg

Facility

$3.00

Service Code	HCPCS J2919
Hospital Charge Code	4401949
Hospital Revenue Code	636
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$2.40
Rate for Payer: Aetna of NY Medicare	$1.38
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$1.20
Rate for Payer: Cash Price	$2.25
Rate for Payer: Cash Price	$2.25
Rate for Payer: CDPHP Medicare	$1.11
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$0.24
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$2.40
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$2.40
Rate for Payer: EmblemHealth Medicaid	$2.40
Rate for Payer: EmblemHealth Medicare	$1.02
Rate for Payer: EmblemHealth Select Care	$0.24
Rate for Payer: Fidelis Medicare	$1.20
Rate for Payer: Galaxy Health Commercial	$1.95
Rate for Payer: Hamaspik Choice Medicare	$1.20
Rate for Payer: Humana Medicare	$1.20
Rate for Payer: Local 1199SEIU Medicare	$1.38
Rate for Payer: MVP Health Care of NY Commercial	$2.25
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$1.69
Rate for Payer: MVP Health Care of NY Medicare	$1.26
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$0.45
Rate for Payer: United Healthcare Medicare	$1.20
Rate for Payer: WellCare Medicare	$1.65

INJECTION, TRIAMCINOLONE ACETONIDE, NOT OTHERWISE SPECIFIED, 10 MG

Facility

$255.45

Service Code	HCPCS J3301
Hospital Charge Code	4400849
Hospital Revenue Code	636
Min. Negotiated Rate	$0.90
Max. Negotiated Rate	$166.04
Rate for Payer: Aetna of NY Commercial	$140.50
Rate for Payer: Cash Price	$191.59
Rate for Payer: Cash Price	$191.59
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$0.90
Rate for Payer: EmblemHealth Select Care	$0.90
Rate for Payer: Galaxy Health Commercial	$166.04
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$140.50
Rate for Payer: WellCare Medicare	$140.50

INJECTION, TRIAMCINOLONE ACETONIDE, NOT OTHERWISE SPECIFIED, 10 MG

Facility

$255.45

Service Code	HCPCS J3301
Hospital Charge Code	4400849
Hospital Revenue Code	636
Min. Negotiated Rate	$0.90
Max. Negotiated Rate	$204.36
Rate for Payer: Aetna of NY Medicare	$117.51
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$102.18
Rate for Payer: Cash Price	$191.59
Rate for Payer: Cash Price	$191.59
Rate for Payer: CDPHP Medicare	$94.52
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$0.90
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$204.36
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$204.36
Rate for Payer: EmblemHealth Medicaid	$204.36
Rate for Payer: EmblemHealth Medicare	$86.85
Rate for Payer: EmblemHealth Select Care	$0.90
Rate for Payer: Fidelis Medicare	$102.18
Rate for Payer: Galaxy Health Commercial	$166.04
Rate for Payer: Hamaspik Choice Medicare	$102.18
Rate for Payer: Humana Medicare	$102.18
Rate for Payer: Local 1199SEIU Medicare	$117.51
Rate for Payer: MVP Health Care of NY Commercial	$191.59
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$143.82
Rate for Payer: MVP Health Care of NY Medicare	$107.29
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$1.67
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$38.32
Rate for Payer: United Healthcare Commercial	$1.67
Rate for Payer: United Healthcare Medicare	$102.18
Rate for Payer: WellCare Medicare	$140.50

INJECT TRIGGER POINTS =/> 3

Facility

$941.00

Service Code	HCPCS 20553
Hospital Charge Code	4856669
Hospital Revenue Code	761
Min. Negotiated Rate	$141.15
Max. Negotiated Rate	$752.80
Rate for Payer: Aetna of NY Commercial	$658.70
Rate for Payer: Aetna of NY Medicare	$432.86
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$376.40
Rate for Payer: Cash Price	$705.75
Rate for Payer: CDPHP Medicare	$348.17
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$752.80
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$752.80
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$752.80
Rate for Payer: EmblemHealth Medicaid	$752.80
Rate for Payer: EmblemHealth Medicare	$319.94
Rate for Payer: EmblemHealth Select Care	$677.52
Rate for Payer: Fidelis Medicare	$376.40
Rate for Payer: Galaxy Health Commercial	$611.65
Rate for Payer: Hamaspik Choice Medicare	$376.40
Rate for Payer: Humana Medicare	$376.40
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$658.70
Rate for Payer: Local 1199SEIU Medicare	$432.86
Rate for Payer: MVP Health Care of NY Commercial	$705.75
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$529.78
Rate for Payer: MVP Health Care of NY Medicare	$395.22
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$141.15
Rate for Payer: United Healthcare Medicare	$376.40
Rate for Payer: WellCare Medicare	$517.55

INJECT TRIGGER POINTS =/> 3

Facility

$941.00

Service Code	HCPCS 20553
Hospital Charge Code	4856669
Hospital Revenue Code	761
Min. Negotiated Rate	$611.65
Max. Negotiated Rate	$611.65
Rate for Payer: Cash Price	$705.75
Rate for Payer: Galaxy Health Commercial	$611.65

INJECT TRIGGER POINTS =/> 3

Facility

$941.00

Service Code	HCPCS 20553
Hospital Charge Code	4850173
Hospital Revenue Code	761
Min. Negotiated Rate	$611.65
Max. Negotiated Rate	$611.65
Rate for Payer: Cash Price	$705.75
Rate for Payer: Galaxy Health Commercial	$611.65

INJECT TRIGGER POINTS =/> 3

Facility

$941.00

Service Code	HCPCS 20553
Hospital Charge Code	4850173
Hospital Revenue Code	761
Min. Negotiated Rate	$141.15
Max. Negotiated Rate	$752.80
Rate for Payer: Aetna of NY Commercial	$658.70
Rate for Payer: Aetna of NY Medicare	$432.86
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$376.40
Rate for Payer: Cash Price	$705.75
Rate for Payer: CDPHP Medicare	$348.17
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$752.80
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$752.80
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$752.80
Rate for Payer: EmblemHealth Medicaid	$752.80
Rate for Payer: EmblemHealth Medicare	$319.94
Rate for Payer: EmblemHealth Select Care	$677.52
Rate for Payer: Fidelis Medicare	$376.40
Rate for Payer: Galaxy Health Commercial	$611.65
Rate for Payer: Hamaspik Choice Medicare	$376.40
Rate for Payer: Humana Medicare	$376.40
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$658.70
Rate for Payer: Local 1199SEIU Medicare	$432.86
Rate for Payer: MVP Health Care of NY Commercial	$705.75
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$529.78
Rate for Payer: MVP Health Care of NY Medicare	$395.22
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$141.15
Rate for Payer: United Healthcare Medicare	$376.40
Rate for Payer: WellCare Medicare	$517.55

Know your out-of-pocket cost for care.

All Charges